NATIONAL VILLAGE HEALTH TEAMS (VHT ... - Ministry of Health
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1 MINISTRY OF HEALTH NATIONAL VILLAGE HEALTH TEAMS (VHT) ASSESSMENT IN UGANDA Submitted to Ministry of Health MARCH 2015
Transcript of NATIONAL VILLAGE HEALTH TEAMS (VHT ... - Ministry of Health
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MINISTRY OF HEALTH
NATIONAL VILLAGE HEALTH TEAMS (VHT)
ASSESSMENT IN UGANDA
Submitted to
Ministry of Health
MARCH 2015
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Abbreviations and Acronyms
ADB African Development Bank
ACTs Artemisinin Combined Therapy
AVSI Association of Volunteers in International Service
AMREF African Medical Research Foundation
ASARECA Association for Strengthening Agricultural Research in Eastern and Central
Africa
AIDS Acquired Immune Deficiency syndrome
CAAIP Agricultural Infrastructure Improvement Programme
CAO Chief Administrative Officer
CDO Community Development Officer
CHW Community Health Worker
CIAT International Centre for Tropical Agriculture
DG Director General
DHO District Health Officer
DHT District Health Team
GISO Gombolola Internal Security Officer
FAWEU Forum for African Women Educationalists Uganda
FGD Focus Group Discussion
HC Health Centre
HCW Health Care Workers
HIV
HSSP
Human Immunodeficiency Virus
Health Sector Strategic Plan
HSSIP Health Sector Strategic Investment Plan
IDC Ideal Development Consults Ltd
IDI Infectious Disease Institute
IEC Information Education Communication
IPs Implementing Partners
KII Key Informant Interviews
LC Local Council
MDG Millennium Development Goal
MoH Ministry of Health
MUAC Mid Arm Circumference
mTrac Mobile Tracking
NAADS
NCDs
National Agricultural Advisory services
Non Communicable Diseases
NGO Non-Governmental Organization
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NTDs Neglected Tropical Diseases
ORS Oral Rehydration Solution
PIU Pathfinder International Uganda
RUFORUM Regional Universities Forum
RDC Resident District Commissioner
RDT Rapid Diagnostic Tests
SACCO Savings and Credit Cooperative Organization
SPSS Statistical Package for Social Scientists
SPRING Strengthening Partnerships, Results and Innovations in Nutrition Globally
SHSSPP Support to Health Strategic Sector Plan Project
STAR EC Strengthening TB and HIV & AIDS Responses in East-Central Uganda
TBA Traditional Birth Attendants
TB Tuberculosis
TEREWODE Association for the Rehabilitation and Re-Orientation of Women for
Development
TORs Terms of Reference
ToT Training of Trainers
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
VHTs Village Health Teams
WHO World Health Organization
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Table of Contents
Abbreviations and Acronyms ........................................................................................................... 2
Table of Contents ................................................................................................................................... 4
Foreword .................................................................................................................................................. 6
Acknowledgement ................................................................................................................................ 7
Executive Summary .............................................................................................................................. 9
1.0 Introduction ................................................................................................................................... 14
1.1 Definition of Village Health Teams and Functions ........................................................ 14
1.2 The History of Community Health Worker Programmes Around the World ................ 14
1.3 Evolution of VHTs in Uganda ......................................................................................... 16
1.4 VHT Roles and Services Globally ................................................................................... 16
1.5 Selection of VHTs............................................................................................................ 17
1.6 Performance .................................................................................................................. 18
1.7 Incentives ....................................................................................................................... 18
1.8 Justification of the Assessment ..................................................................................... 19
2.0 Objectives .................................................................................................................................. 19
2.1 General Objective ........................................................................................................... 19
2.2 Specific Objectives .......................................................................................................... 19
3.0 Methodology ............................................................................................................................ 20
3.1 Study Setting .................................................................................................................. 20
3.2 Study Design and Sampling ............................................................................................ 20
3.3 Study Respondents ........................................................................................................ 21
3.4 Quality Control ............................................................................................................... 22
3.5 Data Management and Analysis .................................................................................... 22 3.5.1 Data Management ............................................................................................................................. 22 3.5.2 Data Analysis .................................................................................................................................... 22
3.6 Ethical considerations .................................................................................................... 23
3.7 Limitations of the Assessment ....................................................................................... 23
4.0 Findings and discussion ........................................................................................................ 23
4.1 Introduction.................................................................................................................... 24
4.2 Number and Socio-demographics of VHTs in Uganda (Objective 1) ............................. 24 4.2.1 Age of VHTs ...................................................................................................................................... 24 4.2.2 Sex of the VHTs ................................................................................................................................. 25 4.2.3 Level of education of VHTs ............................................................................................................... 26 4.2.4 VHT Education Level by Age ............................................................................................................ 27 4.2.5 Relationship between level of education and sex .............................................................................. 28
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4.2.6 Marital Status of VHTs ...................................................................................................................... 29
4.3 Training provided to Village Health Teams (Objective 2) .............................................. 31 4.3.1 Retention and Training of District Trainers ...................................................................................... 31 4.3.2 Training of VHTs ............................................................................................................................... 31 4.3.3 Refresher Training ............................................................................................................................ 34 4.3.4. Who Conducts the Training? ............................................................................................................. 35 4.3.5 Who Supports the Training? .............................................................................................................. 35
4.4 Partners working with VHTs and the activities VHTs are currently Implementing (Objective 3) .................................................................................................................................. 38
4.4.1 Partners supporting and working with VHTs .................................................................................... 39 4.4.2 Activities VHTs are Currently Implementing .................................................................................... 41
4.5 Extent to which the VHT implementation guidelines are being implemented by the Ministry of Health, the Districts and Partners (Objective 4) ...................................................... 44
4.5.1 Introduction ....................................................................................................................................... 44 4.5.2 Selection of VHTs .............................................................................................................................. 44 4.5.3 Training ............................................................................................................................................. 47 4.5.4 Supervision ........................................................................................................................................ 48 4.5.5 Reporting by VHTs ............................................................................................................................ 51 4.5.6 Reporting tools for VHTs................................................................................................................... 53 4.5.7 Coordination of VHT programme ..................................................................................................... 54 4.5.8 Referrals ........................................................................................................................................... 55
4.6 Approaches for Motivation Mechanisms and arrangements (Objective 5) .................. 57 4.6.1 Volunteerism in the VHT programme ................................................................................................ 57 4.6.2 Motivation of VHTs ........................................................................................................................... 58 4.6.3 Suggested VHT motivation mechanisms and arrangements ............................................................. 63 4.6.4 Existing equipment and supplies for VHT ......................................................................................... 64
4.7 Functionality of the VHT Programme (objective 6) ....................................................... 66 4.7.1 Functionality of the VHT programme at national level. .................................................................... 66 4.7.2 Functionality of the VHT programme at district level ...................................................................... 69 4.7.3 Functionality of the VHT Programme at Community Level .............................................................. 70 4.7.4 Functionality of Iindividual VHT Members ....................................................................................... 73 4.7.5 VHT drop outs (Attrition) .................................................................................................................. 73 4.7.6 Sustainability of the VHT programme ............................................................................................... 74
4.0 Discussion ...................................................................................................................... 76
5.0 Recommendations ........................................................................................................ 83
6. 0 Appendices ..................................................................................................................... 88 Appendix 6.1 Number of VHTs in the districts ............................................................................................... 88 Appendix 6.2 National Partners for interview ............................................................................................... 91 Appendix 6.3 List of partners working with VHTs in districts ....................................................................... 91 Appendix 6.4 List of partners interviewed at district level .......................................................................... 110 Appendix 6.5 Ministry of health KIIs ........................................................................................................... 113 Appendix 6.6 VHT Questionnaire ................................................................................................................ 114 Appendix 6.7 Questionnaire for Ministry of Health officials ........................................................................... 122 Appendix 6.8 Partner interview guide .......................................................................................................... 124 Appendix 6.9 Health Centre interview guide ............................................................................................... 127 Appendix 6.10 Community interview guide .................................................................................................. 129 Appendix 6.11 District key informant Guide (LCV Chairman, CAO, RDC) ................................................. 130
7.0 References .............................................................................................................................. 131
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Foreword Uganda’s health indicators on maternal mortality, child mortality and morbidity remain high
despite continued investment in maternal, neonatal and child health. According to the HSSIP
(Health Sector Strategic Investment Plan) 2000/01 – 2005/06, the key challenge to the health
care system was to extend basic health care services to the entire population especially in rural
areas where access to health care is limited. It is in this regard that HSSP I recommended
establishment of VHTs and HSSP II and HSSP III called for roll out and consolidation of the VHT
strategy respectively.
The Ministry of Health established Village Health Teams (VHTs) in 2001 as a means to close the
gap in delivery of health services to the households. Strategy and implementation guidelines
were developed and distributed to the development partners and the districts to utilize in
establishing, training and motivating the VHTs to undertake their activities.
A number of districts and partners have established and trained VHTs in their operational areas
with and without guidance of MOH. In some instances, partners have taken up VHTs, provided
training on their programmatic areas without the basic/core training required of VHTs using the
MOH VHT training manual. This therefore leaves a gap in operational means of VHTs.
The Ugandan MOH, with partners, commissioned a VHT assessment to establish and ascertain
the number, coverage and functionality of VHTs in the country to be able to come up with an
improvement framework.
I am confident that this document will provide guidance to stakeholders to improve the VHT
strategy in Uganda.
Dr Ruth Aceng
Director General, Ministry of Health.
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Acknowledgement The Ministry of Health would like to acknowledge the efforts of a number of organizations and
individuals who contributed immensely to the success of the assessment. Financial assistance
was provided by the United Nations Population Fund (UNFPA) and the GAVI HSS (Health Sector
Support). The United Nations Children’s Fund (UNICEF) and World Health Organization (WHO)
provided technical support into the assessment. Pathfinder International Uganda coordinated
the process of carrying out the entire assessment. We are grateful to all the implementing
partners who have supported the VHT programme and who contributed to the success of the
assessment.
We are grateful to Ideal Development Consults Ltd for ably carrying out the assessment
particularly; Prof. Christopher Orach, Mr. Julius Twinamasiko, Dr. Frank Kaharuza, Dr. Stella
Neema, Mr. Richard Opio and Ms. Alice Ladur.
We are grateful for the efforts of officials at local government level who supported the
assessment by providing the necessary data. We highly appreciate all the hard work of field
staff and, most importantly, the contributions of survey respondents whose participation was
critical to the successful completion of this assessment.
The Ministry of Health would like to particularly thank the following task force for participating
in the difference stages of the assessment including reviewing the report.
No Name Title Organization
1 Dr. Christopher Oleke National VHT Coordinator Ministry of Health
2 Ms. Roseline Achola NPO-Maternal Health-Reproductive
Health CS
UNFPA
3 Mr. Benjamin Sensasi National Professional Officer (NPO)-
Health Promotion and Communication
WHO
4 Ms. Lucy Shillingi Country Representative Pathfinder-Uganda
5 Ms. Caroline Nalwoga Ssekikubo Monitoring and Evaluation Specialist Pathfinder-Uganda
6 Mr. Charles Muhumuza Consultant Ministry of Health
7 Ms. Flavia Mpanga Health Specialist UNICEF
8 Ms. Margaret Waithaka Research and Metrics Advisor Pathfinder-HQ
9 Ms. Tara Acton Senior Program Officer Pathfinder-HQ
10 Ms. Camille Collins Lovell Technical Advisor for Behavior Change Pathfinder-HQ
11 Ms. Minal Rahimtoola Technical Advisor for Health Systems
Strengthening
Pathfinder-HQ
11 Dr. Fredrick Makumbi Researcher Makerere University
School of Public Health
12 Dr Modibo Kassogue Chief, Child Health & Dev’t UNICEF
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Source: Uganda Bureau of Statistics, 2014
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Executive Summary
Background
Uganda adopted the Village Health Teams (VHTs) strategy in 2001 as a bridge in health service
delivery between community and health facilities. This assessment sought to establish the VHT
programme functionality in Uganda.
The overall ojective of the assessment was to establish the national status and functionality of
VHTs in Uganda in order to improve the planning and delivery of health services to households
and communities. The specific objectives of the assessment were: 1) To establish the number
and socio demographic profiles of the VHTs in Uganda; 2) To establish the training that was
provided to the VHTs (VHT training, duration of the training, the content, methods and
materials used for the training); 3) To establish the partners working with VHTs and the
activities VHTs are currently implementing; 4) To review the extent to which the VHT
implementation guidelines are being implemented by the MOH and the districts and partners;
5) To identify approaches for VHT motivation mechanisms and arrangements and lastly, 6) To
assess the functionality of VHTs in Uganda.
Methods
The assessment employed a cross-sectional study design using qualitative and quantitative
techniques of data collection. The assessment was conducted in all 112 districts in Uganda from
November 2014 to January 2015. Individual interviews were conducted with a total of 2,610
VHT members, 224 health workers and 112 VHT focal persons. Key informant interviews (KIIs)
were conducted with 112 district partners and 200 district leaders including Resident District
Commissioners, Local Council V Chairpersons and Chief Administrative Officers. Additionally,
key informant interviews were conducted with seven Ministry of Health officials and 13 national
partners. Focus group discussions were conducted with 112 District Health Team (DHTs) and 30
community groups.
Results
Objective 1: To establish the number and socio demographic profiles of the VHT in Uganda:
Overall, we found a total of 179,175 VHT members in the country. Thirty percent of these do
not have basic training. More than half (52%) of the VHTs had a minimum of ‘O’ Level
qualification. The highest level of education attained by some VHTs (0.4%) is University. Slightly
more than 1% (1.3 %) of the VHTs interviewed had no formal education, of which 82% are VHTs
in Karamoja region.
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Objective 2: To establish the training provided to VHTs: We found that the majority (84%) of
the 112 districts had VHT trainers. Almost half (47%) of the districts had training of trainers
(TOTs) in the last 4 years. TOTs were largely conducted by the Ministry of Health. Fifty percent
of the districts have more than 75% active Trainers. Most VHTs (91.1%) have had initial training.
Overall, more than half of the VHTs were trained for 5-7 days. This duration is too short
compared to the content of VHT Training manual and the ever increasing roles of VHTs. The
main contents of the basic trainings were disease prevention, health education, community
mapping, community registers, home visits, community mobilization and referrals. The initial
trainings were conducted based on MoH guidelines. On average, VHTs had generally received 6
refresher trainings after the basic training. The refresher trainings were varied in content,
duration and methodology.
Objective 3: To establish the partners working with VHTs and the activities VHTs are currently
implementing: The roles VHTs play include mobilization of communities to access health
interventions such as immunization, mosquito nets distribution, fistula services, HIV/AIDS
counselling and testing services. VHTs conduct community sensitizations on disease prevention
such as hygiene and sanitation practices e.g. hand washing, construction of pit latrines and
drinking boiled water, importance of uptake of health services e.g. HIV testing, antenatal care
and family planning. They were also actively involved in treatment of common ailments such as
malaria, diarrhea and promotion of health services including immunization activities, identifying
patients suffering from neglected tropical diseases (NTDs) in their communities. VHTs were
also involved in distributing contraceptives such as condoms. They were also instrumental in
the distribution of drugs mainly deworming tablets and anti-malaria in the communities to
population groups such as children under five.
Partners
The study established that several implementing partners (IPs) (109) are working with districts
to support VHT activities. These include the UN agencies UNFPA, WHO, UNICEF and UNDP,
implementing partners including Pathfinder International, World Vision, Malaria Consortium,
PACE, AMREF, Baylor Uganda and several CBOs. These IPs provided financial, technical and
logistical supports to the VHT programme. The partners were using the MoH VHT guidelines in
the implementation of VHT activities.
Although there are many partners supporting VHT implementation in the districts, they are not
equitably distributed in geographical distribution and their activities as shown in the
concentration of partners in some districts and not in the others. Even in districts, partner
activities are concentrated in some sub-counties and not in others.
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Objective 4: To review the extent to which the VHT implementation guidelines are being
implemented by the MOH, districts and partners: Overall, there was adherence to the MoH
guideline for VHT recruitment and selection in most districts. Supervision of VHT activities
varied across the districts. What was however common was the involvement of the IPs, DHTs
and the district leaders in supervising VHT activities either directly or indirectly. The assessment
did not validate the extent of this supervision since no supervision reports were found.
A general hierarchical VHT reporting from the village through the parish (health centre), sub-
county to the district level exists as evident in some districts. In a few districts such as Otuke,
Sheema and Buhweju, there was practically no reporting due to the absence of a reporting
format/tool and lack of training. It was also found that there is non-uniformity in reporting
tools amongst IPs.
Objective 5: To identify approaches for VHT motivation: Monetary and non-monetary forms of
VHT motivation were mentioned. Financial motivation included lunch and transport allowances,
activity and monthly allowances. Non-monetary forms of motivation included verbal
recognition and appreciation on media and on public occasions. Capacity building in the forms
of educational short courses, trainings and mentorship were cited as ways of motivating VHTs.
Provision of tools and supplies such as uniforms, bags, gum boots, umbrellas, identity cards,
bicycles, among others and provision of special rewards for VHT were also mentioned.
These forms of motivation were found to be non-uniform and irregular amongst IPs. This
resulted into demotivation among some VHTs. Monetary motivation was largely provided by
IPs. As a result, VHTs efforts are concentrated more on IPs programmes compared to
Government programmes. This in effect lessened government ownership of the VHT
programme.
Objective 6: To assess the functionality of VHTs in Uganda: In terms of governance, the
assessment found that there is a coordination office at the national level for the VHT
programme. However, this office is incapacitated by lack of staff, logistics and inadequate
and/or inaccessibly funding for VHT implementation, coordination, monitoring and supervision
of the entire programme. This is reflected in the ever reducing funds that come from
government since the inception of the programme.
At the district level, functionality of the VHT programme is weak due to lack of funding to the
programme both from the center and the districts. Districts do not have databases for the VHTs
and lack evidence of monitoring, supervision and coordination of the VHT programme. The
districts reported that VHTs are being supervised by in-charges of health centers, Health
Inspectors, Assistants and Educators. However, these workers were found to lack facilitation in
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terms of transport and some of them were neither oriented to the VHT strategy nor formally
mandated to monitor and supervise VHT activities.
At community level, the programme was appreciated in the rural communities while urban
communities did not know or knew little about the programme. This calls for more sensitization
of the urban communities on the roles of VHTs.
At individual VHT level, although most of the VHTs reported having been supervised, there was
no evidence of supervision in form of reports at the nearest health facility or district. The VHTs
reported multiple reporting requirements from partners which is a burden to VHTs especially
those with low or no education.
Conclusion
The assessment has shown that the VHT strategy has been implemented to varying levels
across the districts. Funding of the programme by government has been gradually reducing
since its inception, leaving the IPs to fund most of the activities. Districts have different levels
of capacity to coordinate, train and supervise VHT activities but have been hampered by lack of
funds. Coordination and support supervision to partners and districts by the MoH have not
been conducted as desired due to funding constraints.
Recommendations
1. There is need to review the whole strategy of VHT including selection, training,
contents, redefinition of roles and responsibilities of VHTs, and coordination structure at
the national and district level.
2. Government should have a clear commitment to adequately finance and
institutionalized the VHT strategy and ensure regular payments of VHTs for
sustainability of the programme.
3. A strong VHT coordination structure as well as clear monitoring and supervision
mechanisms should be established at all levels of government.
4. The Ministry of Health should establish an accurate data base for VHTs at the national
level to aid monitoring and supervision of the programme. Each district should also be
helped to create district specific VHT data base.
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5. Ministry of Health should streamline training and refresher courses for VHTs to ensure
quality, equity in capacity building for all VHTs and control over VHT activities.
6. Lastly, government and all relevant stakeholders should avail conducive working
environment for VHTs. This should include efforts to improve working relationships
between VHTs and health workers and supporting economic development opportunities
for VHTs.
Women Focus Gropu Discussion in Masaka district, 2-12-2014
Mixed Focus Group Discussion in Sembabule district, 11-12-2014
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1.0 Introduction
1.1 Definition of Village Health Teams and Functions
According to the VHT Strategy and Operational Guidelines , the Village Health Team is a non-
statutory community (village) structure selected by the people themselves to manage all
matters related to health and cross-cutting issues. The Village Health Teams are chosen by their
own communities to promote health and wellbeing of all village health members (MoH, 2009).
The basic functions of VHTs articulated in the VHT Strategy and Operational Guidelines include
community information management, health promotion and education, mobilization of
communities for utilization of health services and health action, simple community case
management and follow up of major killer diseases (malaria, diarrhoea, pneumonia and
emergencies, care of new-born and distribution of health commodities (MoH, 2009).
1.2 The History of Community Health Worker Programmes Around the World
The concept of using community members to render certain basic health services to the
communities from which they come has been in existence for at least 50 years. The Chinese
barefoot doctor programme is the best known of the early programmes, although Thailand, for
example, has also made use of village health volunteers and communicators since the early
1950s (Kauffman & Myers, 1997; Sringernyuang, Hongvivatana & Pradabmuk, 1995).
The barefoot doctors were health auxiliaries who began to emerge from the mid-1950s and
became a nationwide programme from the mid-1960s, ensuring basic health care at the
brigade (production unit) level (Zhu et al., 1989; see also Hsiao, 1984; Sidel, 1972; Shi, 1993).
Partly in response to the successes of this movement and partly in response to the inability of
conventional allopathic health services to deliver basic health care, a number of countries
subsequently began to experiment with the village health worker concept (Sanders, 1985).
The early literature emphasizes the role of the village health workers (VHWs), which was the
term most commonly used at the time, as not only (and possibly not even primarily) a health
care provider, but also as an advocate for the community and an agent of social change,
functioning as a community mouthpiece to fight against inequities and advocate community
rights and needs to government structures: in David Werner’s famous words, the health worker
as “liberator” rather than “lackey” (Werner, 1981). This view is reflected in the Alma Ata
Declaration, which identified Community Health Workers (CHWs) as one of the cornerstones of
comprehensive primary health care.
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Examples of VHW initiatives in Africa driven by this rationale include Tanzania’s and
Zimbabwe’s VHW programmes in their early phase. Both were set in the political context of
wholesale systemic transformation (decolonization and the Ujamaa movement in Tanzania, and
the liberation struggle in Zimbabwe), and both focused on self-reliance, rural development and
the eradication of poverty and societal inequities.
The economic recession of the 1980s, which seriously jeopardized particularly the economies of
developing countries, and brought shifts in the policy environment as the focus on liberation,
decolonization, democratization, self-reliance and the “basic needs” approach to development
was replaced by World Bank-driven policies of structural adjustment and its successors. CHW
programmes were the first to fall victim to new economic stringencies and most large-scale,
national programmes collapsed (although numerous nongovernmental organizations (NGOs)
and faith-based organizations (FBOs) continued to invest in mostly small, community-based
health care). The collapse was further facilitated by the fact that many large-scale programmes
had suffered from a number of conceptual and implementation problems such as “unrealistic
expectations, poor initial planning, problems of sustainability, and the difficulties of maintaining
quality” (Gilson et al., 1989).
While many policy-makers turned their attention away from CHWs altogether, others, wanting
to rescue the concept and practice, suggested subtle shifts, as the following quote from a WHO
publication on CHWs illustrates:
CHW programs have a role to play that can be fulfilled neither by formal health services
nor by communities alone. Ideally, the CHW combines service functions and
developmental/promotional functions that are, also ideally, not just in the field of
health….Perhaps the most important developmental or promotional role of the CHW is
to act as a bridge between the community and the formal health services in all aspects
of health development….the bridging activities of CHWs may provide opportunities to
increase both the effectiveness of curative and preventive services and, perhaps more
importantly, community management and ownership of health-related programs…
CHWs may be the only feasible and acceptable link between the health sector and the
community that can be developed to meet the goal of improved health in the near term
(Kahssay, Taylor & Berman, 1998).
Although this concept of CHWs continues to focus on their role in community development and
bridging the gap between communities and formal health services, their role as advocates for
social change has been replaced by a predominantly technical and community management
function. Over the years, and within the prevailing political climate, this pragmatic approach to
CHWs has gained currency, and undoubtedly today constitutes the dominant approach,
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although the fundamental tension between their roles as extension worker and change agent
remains.
1.3 Evolution of VHTs in Uganda
In 200I, the Uganda Health Sector Strategic Plan 1 recommended the establishment of Village
Health Teams (VHTs) to bridge the gap and improve equity in access to health services. The
VHTs were charged with the responsibility to empower communities to take control of their
own health and wellbeing and to participate actively in the management of the local health
services (NHP, 1999). The decision to establish VHTs was in line with the Alma Ata (1978) and
the Ouagadougou (2008) Declarations on Primary Health Care.
The roll out of the VHT strategy during 2001 - 2010 faced many challenges including ownership,
sustainability, governance, motivation, selection and training which were flawed in many ways.
In addition, the VHT strategy relied heavily on the concept of volunteerism.
1.4 VHT Roles and Services Globally
The participation of community health workers (CHWs) in the provision of primary health care
has been experienced all over the world for several decades. There is evidence showing that
VHTs can add significantly to the efforts of improving the health of the population, particularly
in those settings with the highest shortage of motivated and capable health professionals1.
The review of CHWs across the globe provide a diverse picture of the current outreach services
of health care workers. The review indicates that a wide range of services are offered by the
CHWs to the community, ranging from provision of safe delivery, counseling on breastfeeding,
management of uncomplicated childhood illnesses, from preventive health education on
malaria, TB, HIV/AIDs, STDs and NCDs to their treatment and rehabilitation of people suffering
from common mental health problems. The services offered by CHWs have helped in the
decline of maternal and child mortality rates and have also assisted in decreasing the burden
and costs of TB and malaria. However, the coverage by such programs and the overall progress
towards achieving the MDG targets is very slow (WHO, Report Global Health Workforce Alliance
Year).
Given the broad role that many CHWs play in primary care, a program must assure that a core
set of skills and information related to MDGs be provided to most CHWs. Therefore, the
curriculum should incorporate scientific knowledge about preventive and basic medical care,
yet relate these ideas to local issues and cultural traditions. They should be trained, as required,
on the promotive, preventive, curative and rehabilitative aspects of care related to maternal,
1 WHO, Global Health Workforce Alliance: Global experience of community health workers for delivery of
health related millennium development goals: A systematic review; country case study and recommendations for integration into national health systems.
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newborn and child health, malaria, tuberculosis, HIV/AIDs as well as other communicable and
non-communicable diseases. Other training content and training duration may be added
pertinent to the specific intervention that the CHW is expected to work on.
The CHW/VHT programs should be coherently inserted in the wider health system, and CHWs
should be explicitly included within the human resources for health (HRH) strategic planning at
country and local level.
While CHWs may not replace the need for sophisticated and quality health care delivery
through highly skilled health care workers, they could play an important role in increasing
access to health care and services, and in turn, improved health outcomes, as an effective link
between the community and the formal health system, and as a critical component in the
efforts for a wider approach that takes into account social and environmental determinants of
health.
Successful examples are evident by the efforts of the Bangladesh Rural Advancement
Committee (BRAC), Bangladesh for setting up a CHW program based on cumulative experience
and learning2 Brazil is another example where CHWs provide coverage to over 80 million
people3’4 Ethiopia is currently training about 30,000 workers with emphasis on maternal and
child health, HIV and malaria.
Similar programs are also being considered in other developing countries like India, Ghana and
South Africa. In Pakistan, a huge public sector program for training and deploying Lady Health
Workers (LHWs) has been in place since 1994 and has been expanded to cover over 70% of the
rural population with a work force exceeding 90,0005.
1.5 Selection of VHTs
The CHW programs should regulate a clear selection and deployment procedure. Ideally engage
community in planning, selecting, implementing, and monitoring) that reassures appointing
those who certify the course completion and pass the writing or verbal exam at the end of
training. Government should take responsibility in making a transparent system for selection
and deployment and further quality assurance of the regulated set system. On scaling up a
2 Macharia CW, Kogi-Makau W, Muroki NM. Dietary intake, feeding and care practices of children in
Kathonzweni division, Makueni district, Kenya East African Medical Journal 2004;81(8):402- 407. 3 Freedman LP, Waldman R, De Pinho H, Chowdhury M, Rosenfield A. Who’s got the power?:
Transforming health systems for women and children: Earthscan/James & James; 2005 4 WHO, UNICEF, UNFPA, World Bank. Maternal Mortality in 2005 WHO, UNICEF, UNFPA, World Bank;
2006 5 Campbell OM, Graham WJ. Lancet Maternal Survival Series Steering Group. Strategies for reducing
maternal mortality: getting on with what works. Lancet. 2006;368:1284-1299.
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CHW program, decision makers should consider how to link them up with the wider health
system6.
1.6 Performance
For CHW programs to effectively perform, it is vital to lay due emphasis on training and
supervision. Prior experiences have documented that low interest/use by the government,
inconsistent remuneration, inadequate staff and supplies and lack of community involvement
are key factors that negatively impact the CHW program.30 These factors can be alleviated by
certified training and supportive supervision, along with other incentives (financial and
nonfinancial) to keep CHWs satisfied and motivated to perform their duties well. Furthermore,
efforts geared to standardize training and certification for CHW programs, could further provide
a career pathway and enable them to effectively contribute to their communities. A recent
study by Kash et al.7have concluded that certified CHWs are potentially an important health
task force towards improving access to health care and social services and improve utility of
resources to the underserved.
Equipment and Supplies issues such as the reliable provision of transport, drug supplies and
equipment have been identified as another weak link in CHW effectiveness.1 The result is not
only that they cannot do their job properly, but also that their standing in communities is
undermined. Failure to meet the expectations of these populations (with regard to supplies),
destroys their image and credibility. If CHWs are used in programs that have drug treatment at
their core, such as TB DOTS or HAART, the situation becomes more critical but most programs
include the need for supply of drugs and/or equipment, including transport.1 Ideally, supplies
and equipment should be organized through district or regional dispensaries, and collected and
delivered by CHWs.1 In cases where villages are very remote to the central health centre,
village dispensaries can be established to cater for the drug needs of the populations.48
Equipment and supplies may be added pertinent to the specific intervention that the CHW is
expected to work on.
1.7 Incentives
Keeping in mind the dearth of health workers and the rising need of CHWs to meet the health
care demands, it is imperative to prevent dropouts from training programs. CHWs are poor
people, living in poor communities, and thus require income. From the global and country case
studies review we found that programs pay their CHWs either a salary or an honorarium and
6 6 WHO, Global Health Workforce Alliance: Global experience of community health workers for delivery
of health related millennium development goals: A systematic review; country case study and recommendations for integration into national health systems. 7 Kaseje MA, Kaseje DC, Spencer HC. The training process in community-based health care in Saradidi,
Kenya. Annals of Tropical Medicine and Parasitology. 1987;81 (Suppl 1):67-76.
19
almost no examples exist of sustained community financing of CHWs.1 Even NGOs tend to find
ways of financially rewarding their CHWs. Moreover, control on attrition can be achieved with
regular and performance based financial incentives and hiring CHWs as full time employees
rather than part time volunteers.1 They should also be given a wage if they work as full time,
and those working as part time should be given small incentives for their work. We would make
a strong recommendation for ensuring the CHWs be paid adequate wages commensurate with
their work load and timings. Performance incentives could be the other pay back option, which
can also motivate them to work with full determination. Moreover, in kind awards, such as an
identification pin, can provide a sense of pride in their work and increased status in their
communities.1 In cases where possible, free health coverage for themselves and for their family
should be provided. In the end, we would recommend that CHWs should be given pay for
performance to keep them stimulated8.
1.8 Justification of the Assessment
A number of districts and partners have established and trained VHTs in their operational areas
with or without guidance of MOH. In some instances, partners have taken up VHTs, provided
training on their programmatic areas without the basic/core training required of VHTs using the
MOH VHT training manual. This therefore leaves a gap in operational means of VHTs.
Currently information in relation to number, coverage and functionality of VHTs has gaps. While
the VHT strategy and implementation guidelines are in place, most partners implementing
programs in the communities do not follow the strategy as reflected in the Health Sector
Strategy Investment Plan II (HSSIP II). Therefore the Ugandan MOH, with partners, undertook a
VHT assessment to establish and ascertain the number, coverage and functionality of VHTs in
the country to be able to come up with an improvement framework.
2.0 Objectives
2.1 General Objective
To establish the national status and functionality of VHTs in Uganda in order to improve the planning and delivery of health services to households and communities.
2.2 Specific Objectives
i) To establish the number and socio demographic profiles of the VHT in Uganda.
ii) To establish the training that was provided to the VHT (VHT training, duration of the
training, the content, methods and materials used for the training)
8 Douthwaite M, Ward P. Increasing contraceptive use in rural Pakistan: an evaluation of the lady health
workers programme Health Policy and Management. 2005;20(2):117-123.
20
iii) To establish the partners working with VHTs and the activities VHTs are currently
implementing.
iv) To review the extent to which the VHT implementation guidelines are being
implemented by the MOH and the districts and partners.
v) To identify approaches for VHT motivation mechanisms and arrangements
vi) To assess the functionality of VHTs in Uganda.
3.0 Methodology
3.1 Study Setting
The study was conducted country wide in all the 112 districts in Uganda. The study was
conducted from November 2014 till January 2015.
3.2 Study Design and Sampling
A cross-sectional, mixed-methods study was conducted, that included a structured survey of
Village Health Teams, focus group discussion with District health teams and in-depth
interviews.
The country was subdivided into 10 sub regions (Table 1) following Uganda Bureau of Statistics
(UBOS) criteria. A total of 10 teams consisting of 5-6 members were trained and deployed for
data collection.
Table 1: Districts in the different regions
Region District No of
districts
Karamoja Kaabong, Kotido, Abim, Napak, Moroto,
Nakapiripirit, Amudat,
7
Eastern Kween, Kapchorwa, Bukwo, Sironko, Bulambuli,
Bududa, Manafwa, Mbale, Bukedea, Kumi, Ngora,
Serere, Soroti, Tororo, Amuria, Katakwi, Busia
17
East Central Butaleja, Budaka, Kibuku, Pallisa, Buyende, Kaliro,
Namutumba, Bugiri, Namayingo, Mayuge, Kamuli,
Luuka, Jinja, Iganga
14
Central 1 Kalangala, Masaka, Rakai, Lwengo, Bukomansimbi,
Kalungu, Butambala, Ssembabule, Lyantonde,
Gomba, Mpigi, Mubende, Mityana
13
Central 2 Buikwe, Buvuma, Mukono, Wakiso, Kayunga,
Luwero, Nakaseke, Nakasongola, Kiboga,
10
21
Kyankwanzi
South Western Kiruhura, Mbarara, Ntungamo, Isingiro, Kabale,
Kisoro, Kanungu, Rukungiri, Bushenyi, Sheema,
Mitooma, Buhweju, Ibanda
13
Western Rubirizi, Kasese, Kamwenge, Kabarole, Kyenjojo,
Kyegegwa, Kibale, Bundibugyo, Ntoroko, Hoima,
Masindi, Bulisa, Kiryandongo
13
North Amolatar, Kaberamaido, Dokolo, Apac, Lira, Oyam,
Kole, Alebtong, Otuke, Agago, Kitgum, Lamwo,
Pader, Gulu, Amuru, Nwoya
16
West Nile Nebbi, Zombo, Arua, Adjuman, Moyo, Yumbe,
Koboko, Maracha
8
Kampala Kampala 1
3.3 Study Respondents
Table 2 shows the data collection methods and the respondents that were interviewed. District
leaders including Local Council V Chairman (LCV chairman), Resident District Commissioner
(RDC) and the Chief Administrative Officer (CAO) were purposively selected. Members of the
district health teams were mobilized in each district to participate in a focus group discussion.
At each district, two sub counties were selected at random by drawing from a “hat”. Health
Centre II facilities in the sub counties were also randomly selected. HCIII or higher facilities
were selected if they were in the selected parishes. A minimum of 12 VHT members from the
villages in a parish were selected with the help of Parish VHT supervisors and health entre in-
charges. Focus group discussions were held with 10-12 members selected from community
where the health centre under the assessment is located.
Partner selection was done in consultation with the DHT. The criterion of selection was based
on the “most active" partner in the district in terms of geographical and area of coverage. This
meant that the partner’s contribution to the VHT programme in the district was significant. In
districts where the partner had been interviewed before in the region by the research team,
the second most active partner was then considered.
Data were collected during this assignment through comprehensive review of available
literature from, VHT manual/hand book, VHT Strategy and Operational Guidelines, VHT
register, , Situational analysis of VHT 2009 and other documents deemed relevant. Also teams
extracted reports for review to capture information on VHTs/profile during data collection.
Table 2: Respondents and data collection technique
22
Data collection techniques Category of respondents Actual
Number
Target
number
% of
respondents
interviewed
Desk review Reports and all relevant
documents
Focus Group Interviews District Health teams 105 112 94
Community 30 30 100
Key informant interviews District VHT focal person 112 112 100
Implementing partners
(district level)
70 112 63
District KIs 240 336 71
MOH Officials 7 10 70
Interview Administered
questionnaire
VHT 2610 2688 97
Health care workers 217 224 97
3.4 Quality Control
The research assistants were trained for five days in research methods and data collection tools. Pretesting of the data collection tools for a day prior to data collection was also done. All the tools were translated into the appropriate local languages. The central management team and partners including MoH, Pathfinder International and UNFPA conducted supervision of the data collection. Daily debrief meetings were held with data collectors/research assistants to review questionnaires.
3.5 Data Management and Analysis
3.5.1 Data Management
The quantitative data were checked for completeness prior to capture into an electronic data
base using Statistical Package for Social Scientists (SPSS) Version 20. Qualitative data were
transcribed, cleaned and entered into a master sheet. Trained research assistants under the
guidance of the field supervisor captured data, which were securely kept in password-protected
files.
3.5.2 Data Analysis
Descriptive data analysis was conducted using SPSS Version 20 to obtain frequencies
distributions, graphs and cross tabulations for statistical association. The qualitative data were
analyzed by reviewing the FGD transcripts several times while making notes in the transcripts.
Any disagreements that required further clarity were resolved through discussions among the
data analysis team and data triangulation. These data were then coded, grouped/sorted
23
according to themes and relative occurrence of the responses. Extracted meanings were
summarized according to key /important messages. Thematic and content analysis, summaries,
scenarios were used.
3.6 Ethical considerations
Permission to conduct the study was sought from the district leadership including District
Health Officers (DHOs), Chief Administrative Officers (CAOs) and the Resident District
Commissioners (RDCs). Verbal consent to participate in the survey was sought from all
respondents. In the event that consent was not granted, such respondents were at liberty not
to participate in the study. Maximum confidentiality was observed at all levels of data collection
and processing.
Table 3: Team Composition
Name of Consultant Qualifications Roles
Prof. Christopher
Garimoi Orach
(PhD) in Public Health Team Leader
Dr. Frank M .Kaharuza PhD in Epidemiology Field Coordinator
Mr Julius Twinamasiko MSc Agricultural Economics Cert in
Public Health, Cert in Nutrition Research
Methods
Data Manager
Dr. Stella Neema PhD Anthropology Qualitative Research
lead
Mr Richard Ongom Opio MSc Public Health Qualitative data
analyst
Ms Alice Ladur MSc Public Health Qualitative data
analyst
3.7 Limitations of the Assessment
The timing of the assessment coincided with some major events such as the national
immunisation days and World AIDS Day that made the availability of the key respondents hard.
Some of the district officials could not be reached for this assessment.
4.0 Findings and discussion
24
4.1 Introduction
The findings of the assessment are presented in six sections following the specific objectives of
the study. Section one addresses the socio-demographic profiles of VHTs. Section two focuses
on the training provided to VHTs. Section three addresses activities VHTs are engaged in and
partners supporting the VHT programme. Section four addresses the extent to which the VHT
implementation guidelines were implemented. Section five presents VHT motivation
mechanisms and arrangements and section six addresses the functionality of VHTs.
4.2 Number and Socio-demographics of VHTs in Uganda (Objective 1)
The VHT focal persons reported an estimated total of 179,175 village health team members
from all the 112 districts. The Eastern region had the highest number, followed by South
Western and Western regions. These regions also happen to have the biggest number of
districts. Kampala region has the lowest number, 351, of VHTs (fig 1).
Figure 1: Distribution of VHTs by region
4.2.1 Age of VHTs
The assessment established that the age of VHTs ranged from 18 years to 78 years, with an
average of 40 years. Age was categorized into three groups (Figure 2). The majority of VHTs
(59.3%) were in the age range of 31 to 49 years.
Figure 2: Age group by sex
25
4.2.2 Sex of the VHTs
The majority of the key informant interviews reported the existence of more female VHTs than
male. For instance, in Mitooma district as well as in Kibaale district, this situation and
challenges of gender disparities affecting female VHTs were acknowledged.
“Many of the VHTs are women of which most men overlook them; they say it is a women`s
thing”, KII_ Mitooma district.
“Most VHTs are female, the married ones tend to be bullied by their husbands, tending to
discourage them from that commitment”, KII_ Kibaale district.
While the majority of the sample of VHTs who attended the interviews were male (53.9%), it
should be noted that this may not be a true reflection of the general gender composition of the
VHTs. Rather, it is a reflection of the unbalanced male-female roles in the communities. The
mobilization of the VHTs was undertaken by the districts and it is possible that because the
male VHT always have less domestic chores to do as opposed to female VHTs, the female VHTs
could most likely not reach the interview venues on short notice due the gender roles they play
(Table 4).
Table 4: Sex of the VHTs interviewed
Gender Frequency Percent
Male 1396 53.7
Female 1203 46.3
Total 2599 100.0
No Data provided 11 0.4
26
4.2.3 Level of education of VHTs
Of the VHTs interviewed, the majority (61.2%) had a qualification above primary level (table 5).
Overall, the study found that more than 52% of the VHTs had a minimum of ‘O’ Level
qualification. A few of the VHTs (2.9%) had attained tertiary level of education. 1.3% of the
VHTs interviewed had no formal education, of whom 82% are VHTs in Karamoja region.
Table 5: Education level
Level of education Frequency Percent
No formal education 34 1.3
P1-P4 81 3.1
P5-P7 887 34.3
O-level 1367 52.8
A-level 75 2.9
Vocational 68 2.6
Tertiary 75 2.9
Total 2587 100
Overall, Karamoja region had the highest percentage of VHTs without formal education. Among
VHTS with O-level education and above, Karamoja contributed the least (table 6).
Table 6: Percentage (row) distribution of level of education by region
Region n No
formal
education
P1-P4 P5-P7 O-
level
A-
level
Vocational Tertiary
Northern 352 0.9 1.7 27.8 61.9 1.4 4.3 2
Karamoja 137 20.4 19.0 24.1 32.1 2.9 0.0 1.4
Eastern 438 0.2 2.7 34.5 55.0 3.4 1.4 2.7
Central 1 310 0.0 2.9 37.1 51.0 3.9 1.6 3.5
Central 2 236 0.0 4.2 30.1 53.8 4.2 2.5 5.1
East
Central
341 0.0 2.1 28.2 64.2 4.1 0.6 0.9
West
Nile
203 0.5 2.0 41.9 51.7 2.5 1.0 0.5
Western 259 0.4 1.2 32.0 47.5 2.3 10.4 6.2
South
western
311 0.0 1.3 49.8 42.4 1.3 1.6 3.5
Kampala 20 0.0 0.0 15.0 60.0 5.0 0.0 20
27
However, the criterion of being able to read and write in the local language seems not to have
been followed in some districts such as Kaabong, Napak and Moroto as highlighted by key
informants. A number of VHTs reported not knowing how to read and/or write.
“The general challenge is low literacy rate among VHTs…., there are those who do not know
how to read and write. So we use colours, numbers and pictures to help them identify
(conditions such as) malnutrition, a bleeding woman to show certain aspects of a health
condition or complication”, FGD_DHT, Kaabong district.
4.2.4 VHT Education Level by Age
Figure 3: Percentage of Education Distribution by Age
From the above figure, majority of the VHTs have attained ‘O’ level as the highest level of
education. Qualitative findings from various focus group discussions showed a general
preference for more educated VHTs.
“The minimum level of education for VHTs should be ‘O’ Level. But some of the things we
are (assigning VHTs to do) require someone who has done ‘A’ Level” FGD_DHT,
Lyantonde district.
“..we appreciate the role VHTs have played but where the world has reached , when
recruiting new VHTs, at least the person selected should have completed at least senior
four. It will really help on the people’s side”, Community FGD (Men’s Group), Luwero
district.
28
This finding underpins the need to invest in younger and more educated VHTs for effective
health services delivery. The current National VHT guidelines do not stipulate the age and
education level of VHTs.
4.2.5 Relationship between level of education and sex
Overall, a large percentage of both male (56.2%) and female (49.0%) VHTs had completed O-
level as illustrated in the table 5 above. A higher percentage of females did not have formal
education compared to 0.8% of males.
Table 6: Relationship between level of education and sex
Level of Education Male (n=1396) Female (n=1202)
No formal education 0.8 1.9
P1-P4 2.9 3.3
P5-P7 29.3 39.7
O-level 56.2 49.0
A-level 4.1 1.6
Vocational 2.8 2.4
Tertiary 3.2 1.9
University 0.7 0.2
Total 100 100
The assessment has shown that the education level among the sex groups is generally the
same. A higher proportion of male (60.3%) as compared to female (50.6%) has attained post-
primary education. A higher proportion of female (1.9%) compared to male (0.8%) has no
formal education. It was also noted that about 0.2% of female and 0.7% of male had tertiary
education (table 6).
The majority (~85%) of VHTs is peasant farmers, and this does not vary by sex. No significant
differences were observed in other categories of occupation. It should be noted that some VHT-
members are employs of NGOs (~1.5%) or LC members (~1%), which is inconsistent with the
requirement for being a VHT-member according to the recruitment guidelines.
Table 7: Main Occupation of VHTs
Occupation Male Female
Overall 1313 (100%) 1151 (100%)
Farmer 86.1 85.6
Business/self employed 9.4 11.5
29
Employed by NGO 1.5 1.4
Student 0.7 0.1
Fisherman/fisher flock 0.4 0.2
LC member 0.8 0.9
Boda boda 0.4 0.0
Religious leader 0.7 0.3
Cultural leader 0.0 0.1
4.2.6 Marital Status of VHTs
Nearly 4 in 5 VHT members are married suggesting a degree of stability within their respective
communities (Table 8), and may be more acceptable because of the perceived respect accorded
to such persons in this setting.
Table 8: Marital Status of the VHTs
Status Frequency Percent
Single 129 4.9
Cohabiting 179 6.9
Married 2084 79.9
Separated 56 2.1
Divorced 17 0.7
Widowed 142 5.4
Discussion
Although an estimated 179,175 village health team members were reported by focal persons
for all the 112 districts, nearly a third (30%) did not have basic training. These estimates could
not be verified due to lack of other sources of data such as databases at the district level. This
implies that they are not technically VHT-members according to the
30
.
This means that for 57,735 villages, there is an average of 3 VHTs members serving a village.
This figure, however, may be inaccurate since there are some districts such as Kibuku, Kampala,
among others that have not carried out the basic VHT training. The number of VHTs are as
reported by the districts and could not be independently verified. The regional imbalance in
VHT distribution in VHT coverage requires government to conduct VHT training in districts that
have not yet had their own trainings to ensure equitable delivery of health services.
The assessment found that just over a half (52%) of VHTs were below 40 years of age. They are
able to sensitize the communities on health promotion but also do other health related
activities. This age bracket may be more susceptible to attrition as they are considered more
mobile. Some of the VHTs were 50 years or older, a factor that may have led to inefficiencies
with regards to report writing and swift movement during mobilization activities. For example,
administrators in districts such as Kalungu, Butambala and Mpigi expressed dissatisfaction with
the manner in which the older VHTs were performing in terms of reporting and drug
distribution as well as efficiency in movement during mobilization.
“Some of the VHTs in this area are aged and cannot see well”, FGD_DHT, Butambala district.
Given the unique health challenges of the young people in Uganda, there is need to review the
guidelines for eligibility and recruitment of people to be trained as VHTs to recruit more of 35
years and below to handle young people who are a majority in the population.
While the majority of the VHTs interviewed (54%) were male the assessment could not
establish the exact sex composition of the VHTs in the Country due to the absence of accurate
VHT databases in the districts. Thus future revised recruitment guidelines should consider to fill
in the gender gap by having 50% male and 50% female targets for VHTs.
31
The data shows that more than 50% of the VHTs have attained at least ‘O’ Level education and
can therefore read and write. This position was also supported by community data showing
preference for people who have attained ‘O’ Level education and above. This would imply that
Government could consider the minimum level of education for a VHT member could be ‘O’
Level. This would suit the expanding scope of responsibilities of VHTs such as administering
antimalarial drugs, data gathering and reporting, family planning. However, it should also be
pointed out that there is a challenge of identifying people with ‘O’ Level education in some
places, more especially in Karamoja region, where about 20% of the VHTs had at least ‘O’ Level
education as compared to the rest of the Country.
VHTs are involved in various activities. Although majority of the VHT members were involved in
farming, some are employed by NGOs and others work as Local Council (LC) members and
students. Availability of such cadres to do VHT work may be limited thus affecting their output.
It is also important to note non-adherence of the guidelines when such VHT-members are
involved in VHT work, especially the LC-members who may introduce political interferences.
4.3 Training provided to Village Health Teams (Objective 2)
4.3.1 Retention and Training of District Trainers
Of the 112 districts visited, the majority 94 (84%) reported having VHT trainers in the district
(Table 8). Almost half of the districts had training of district trainers in the last four years. The
majority of the new districts did not have active district trainers. Training of district trainers
were largely conducted by the Ministry of Health while 41% of the districts have more than 75%
active Trainers.
Table 8: Year district trainers were trained
TOT Training Number Percent
Year
2001-2004 14 13
2005-2009 22 20
2010-2014 52 47
Missing 24 21
Total* 112 100
4.3.2 Training of VHTs
Of the 179,175 VHTs as reported by the VHT Focal Persons, only two thirds had received basic
training. While most of the VHTs had undergone the basic training, there were exceptions in
32
the newly created districts such as Bulambuli, Amuria, Dokolo, Kibuku and Buikwe, among
others where VHTs have not undergone the basic training.
“Kibuku as a district has never trained any VHT on comprehensive training apart from
the trainings by NGOs (on specific projects)”, FGD_DHT, Kibuku district.
Fig 3: Distribution of Trained and Untrained VHTs by Region.
0
5000
10000
15000
20000
25000
30000
No
of
VH
Ts
Region
Trained
Not trained
South Western region had the highest number of trained VHTs followed by Northern and
Western regions. The Eastern region had the highest number of untrained VHTs. In Kampala
district, VHTs did not receive basic training. Eastern, East Central and Western regions had very
high numbers of untrained VHTs.
However, in the interviews with selected VHTs, the vast majority of the VHTs (91%) reported
having received basic training. A few of the VHTs could not remember or did not know if they
had received initial training. This may be attributed to the multiplicity of trainings that the VHTs
could not differentiate between basic and refresher training (Table 9). There have been various
kinds of trainings conducted for the VHTs across all the districts.
The basic training is based on the MoH guidelines and originally was designed to last for two
weeks. However, respondents explained that the length of training fell short of two weeks. The
training days were compressed by the Ministry of Health from 14 to five days due to financial
limitations (MoH 2009), though the curriculum was not adjusted to fit in this short time Due to
financial constraints, supervision has not been adequately done to ensure that training is the
same across the board for all VHTs.
“Training of VHT is through the district partners but this is not standardized- trainings
are sometimes different –without a properly laid out approach”, KII_MoH.
33
Program specific trainings have been conducted by various IPs. The program areas included HIV
and TB by STAR EC, malaria and HIV/AIDS by Malaria Consortium, family planning by Pathfinder
International and Reproductive Health Uganda (RHU), hygiene and sanitation by Uganda
Sanitation Fund, neglected tropical disease (NTDs), maternal, new born and child health by
World Vision and nutrition by SPRING, among others. On average, these trainings lasted for 2-5
days. However, very few VHTs have been trained within each district and most often the same
VHT members have been selected for the various trainings. Usually, the most active VHT
members continue to receive these trainings to the disadvantage of those perceived to be
inactive. However, the training of those perceived to be inactive proved successful with the
NTD programme in Serere.
“We tried this with NTD programme where we picked the ones regarded as inactive and
they performed well”, FDG DHT, Serere district.
The majority of interviewed males (90.1%) and females (92.5%) received basic training as
shown below.
Table 9: Basic Training by Sex of the VHTs
Response Males Females
Frequency Percent Frequency Percent
Had initial training 1254 90.1 1109 92.5
Not had initial training 129 9.3 86 7.2
Not sure if had initial
training 9 0.7 4 0.4
Total 1392 100 1199 100
According to the Ministry of Health Operational Guidelines (MoH 2009), basic training of 5 days
is recommended. The study established that the VHT basic training time ranged between 1 to
14 days. Overall, we established that just over half of the VHTs were trained for 5-7 days. Nearly
a third was trained for 1-4 days. Figure 4 below shows period of training given to the VHTs.
Figure 4: Duration of VHT Basic Training
34
29.3
51.8
7.8
Duration of VHT basic training
<1 Week (1-4 days)
1 Week (5-7 days)
2 Weeks (8-14 days)
Training Content
The VHT training content, as per VHT Strategy and Operational Guidelines , is disease
prevention and health promotion, identifying simple illnesses and provision of simple
treatment, identification of danger signs, referral, maintenance of VHT registers and
community mapping.
The most commonly recalled / mention content area for the VHT training was disease
prevention (90.2%), while 63.2% reported having had training in health education, and home
visits (62%) see Table 10.
Table 10: Reported Content of the Basic Training
Content Frequency Percent
Disease prevention 2098 90.2
Health education 1469 63.2
Home visits 1450 62.3
Community mobilization 1255 54.0
Referrals 797 34.3
Community registers 771 33.1
Community mapping 584 25.1
4.3.3 Refresher Training
Refresher training is any additional training conducted after the initial VHT training and is
usually tailor-made to the specific programme needs of the individual implementing partners.
Refresher training is conducted for the various programme areas. It usually lasts 3-6 days and is
conducted by implementing partners. They include training on communicable diseases such as
35
malaria, HIV/AIDS, TB, Pneumonia, hygiene and sanitation, referrals the roles of VHTs, among
others. On average the reported number of additional trainings were 6, but ranged from 1 to
30.
Table 11: Category, Content and Duration of VHT Training
Category Training Content Duration Training Partners
Basic training Community mobilization, Records
keeping, Health promotion,
Prevention , Treating the sick,
Referrals and Home visits
1-14 days
5-7 days (MOH)
MOH with support
from Partners
Refresher
training (disease/
program specific)
Communicable diseases – Malaria,
HIV/AIDs, TB, Pneumonia,
Diarrhea, Hygiene and Sanitation
promotion, eMTCT, Referral,
Diagnostic testing – RDT, Family
Planning, community mobilisation
for health care
Varied 3-6 days Partners with MOH
and District support
“The Ministry also apart from implementing partners should provide resources for
refresher trainings because if a VHT was trained three years ago, things are changing.
Something should be done in trainings”, FGD_DHT, Lamwo district.
“VHTs should have refresher trainings to boost them to carry out their work most
efficiently”, FGD_DHT, Mubende district
4.3.4. Who Conducts the Training?
The VHT initial trainings are conducted by district trainers. District trainers are trained by MoH
master trainers. The master trainers are Ministry of Health staff. Trainings, such as refreshers
or program specific trainings, can be conducted by district health officials, health assistants,
health centre in-charges and some implementing partners.
4.3.5 Who Supports the Training?
The MoH provided support to the VHT training through its master trainers and provision of
guidelines for selecting and training the VHTs as articulated.
“The Ministry of Health would coordinate training and provide guidelines and
information”, KII, MoH.
Several implementing partners helped to support programme specific courses for the VHTs.
These trainings included HIV/AIDS, TB, Malaria, Maternal and Child Health, Hygiene and
Sanitation, Integrated Community Case Management, Neglected Tropical Diseases. (Appendix
6.2)
36
“We trained them to recognize community members in need of rehabilitation and refer
them especially those that need HIV/AIDS testing and counselling and refer them to our
clinic for services. We also trained them to do home visits and do follow up on patients to
make sure they remind them to take and complete medication. We trained them on
counselling and guidance and how to handle properly people living with HIV/AIDS. We
trained them to encourage community members to go for HIV/AIDS testing and to do
community mobilization in case of outreach. We trained them on how to write and what
to capture in reports. We trained them on how to approach people, communicate and
encourage them and how to link them to our clinics or to the nearest health centres”,
KII_Partner, Sheema district.
“Yes, we train them on specific programmes such as nutrition, immunization and general
good health practices”, KII_ Partner, Kiryandongo district.
Discussion
When new VHT Focal Persons in the districts are brought on board they have a difficult time
understanding the effectiveness of the VHT program due to a lack of information on what has
happened in the programme in the previous years. The lack of a database to keep track of this
information also results in not being able to accurately track the number of VHTs and the
trainings they have attended.
Despite the high number of VHTs in the Eastern region, the majority have not had initial VHT
training. The high number of untrained VHTs in Eastern region shows disfunctionality of the
VHT programme. People who did not receive initial training were considered VHT members in
some districts. For example, in Kampala district where no initial training has taken place, 351
people were reported to be VHTs. These were only trained on programme-specific areas. In
such districts, it is apparent that the VHT guidelines have not been followed with respect to
training.
It was noted that the content of the initial training reported by VHTs country-wide was largely
consistent with the content stipulated in the VHT operational guidelines. However, this content
may not have been fully covered in the short duration of the training (5-7 days) even when
qualified trainers were used. The reduction of the training duration by the Ministry of Health
from 10 to 5 days may have led to rushing of the trainings. The trainings may have been
inadequate to equip the VHTs with appropriate knowledge and skills. This therefore could
affect the quality of services VHTs provide to the community.
At times, trainings are conducted directly by the IPs without notifying and involving the DHTs or
using the district trainers. This indicates a problem of VHT programme coordination,
37
streamlining and training. Since IPs choose where to go and implement their programmes, it
creates disparity in the capacity of VHTs since trainings are provided to some VHTs in some
areas and not to others. This leads to differences in knowledge and skills levels among the
VHTs. Such a situation may lead to demotivation of the VHTs and may result into drop out.
Poor IP coordination creates a problem in supervision of the programme and eventually in
sustainability when the partners’ projects end. In areas with few or no implementing partners,
it implies that the communities may not be benefitting from the VHT activities supported by
such partners.
While these multiple trainings can strengthen the capacity of VHTs to deliver services to the
community and provide feedback to the health facility staff, it also means that the same VHTs
receive multiple trainings which increase their reporting burden. It may also mean there is
inadequate time to have quality training given the low level of education of some of the VHTs.
38
4.4 Partners working with VHTs and the activities VHTs are currently Implementing
(Objective 3)
39
4.4.1 Partners supporting and working with VHTs
Several development partners support VHT activities in the districts. These development
partners include UNFPA, WHO, UNICEF, UNDP DFID, USAID, SIDA and others (Appendix 6.2),
They support the programme through the implementing partners that include; Pathfinder
International, RHU, Baylor Uganda, World Vision, PACE, AMREF, Community Based Organizations
such as; Mayanja Memorial, Kagum Development Organization, Uganda Sanitation Fund and
Community Connector among others. However there was no evidence to ascertain the criteria
followed by the IPs in selection of the districts of operation. South western region was found to
have the highest number of implementing partners (table 12).
Table 12: Number of Implementing Partners by Region
Region Number of Partners
Central 1 49
Central 2 41
Eastern 62
East Central 53
Kampala 12
Karamoja 31
Northern 64
South West 69
Western 60
West Nile 20
Development partners have made significant contributions to the overall implementation of the
VHT programme through the provision of financial, technical and logistical support. They
provide financial support to implanting partners to run the VHT programme related
interventions. Such support is used to conduct training, logistics supplies, supervision and
motivation.
“We support partners with money to go and do the work. Training has been done
especially family planning and door to door mobilization, pregnancy mapping and
referrals. We work in Yumbe, Oyam, Kotido, Moroto, Kabong, Katakwi, Mubende and
Kanungu. We give money to the Local Governments, Pathfinder International and
Reproductive Health Uganda. On top of family planning, these partners support VHTs.
CDFU radio health choice programme is one of the programmes supported by the
partners. During radio shows, VHTs mobilize people to listen to the programme”,
KII_UNFPA, National Partner.
40
“We trained 125 VHTs and we give them 25,000= per month for bicycle maintenance
facilitation. They qualify for this facilitation upon the submission of a report and
attending a monthly meeting. The health assistant is provided with a tracking system
that he fills while supervising them” KII_Baylor Uganda, Serere district.
“We also support VHT quarterly meeting with allowance of 7,000= given to every VHT
member. We usually support the health center in-charges throughout the district through
the provision of airtime of 5,000= per month to enable them to easily coordinate with the
VHT within their respective health facility”, KII_Malaria Consortium, Mbale district.
Improvement in the VHT program has been reported in districts and or sub counties where IPs
have been operating as earmarked by regular reporting, supervision and activeness of VHTs.
“Sub-counties that have implementing partners are performing so well as compared to
those without partners”. FGD_DHT Busia
“The VHTs getting support from partners have a stronger system and work better than
those who are not getting any support or those working as volunteers”, Community
FGD_Masaka district.
The presence of partners and VHT engagement in the districts is largely tailored to the specific
program interests of IPs as reported in this extract from Dokolo District Health Team.
“Most of these trainings have been conducted by partners. NUHITES support them
(VHTs) in training and equipping them with what they call MUAC tapes, tape for
measuring the upper arm circumference and then they use that for assessment of
nutrition. There is Uganda Sanitation Fund that supports sanitation at home stead, some
facilitation to make them do sensitization on sanitation in households. Then ABT
associates have come in now; they are training them to be pump operators, spray pump
operators. If a partner comes for a particular disease that is there, another one comes
like that, may be specifically for malaria, and may be for NTDs, it’s not the same
partners”. FGD_DHT Dokolo
As reported by the district health teams during Focus Group Discussions, implementing partners
were not coordinated in offering their support to the VHTs. For example, they motivated VHTs
differently; they had different reporting formats and their programme training followed
different methodologies and the duration was different. This led to motivation of some VHTs
more than others which may have led to drop outs and reduced enthusiasm at work. Moreover,
partners were concentrated in some districts leaving others with few or no partners.
“different partners have different areas of interest e.g. Marie Stopes focuses on family
planning but again when they come in and they want VHTs we tell them to select VHTs
already selected by the community and for the content we select and train using the
41
manual. Partners come in with a specific agenda much as we are mandated to gate keep
them and sometimes it isn’t easy. So we just may be say let’s pick on what we can get
though the training is supposed to follow the guideline. We wish partners to give them
the training for the entire package but they say they can’t afford that”, FGD_DHT,
Sheema district.
“The partners have no well-organized guidelines. For example, Crane Health Services has
a different package”, FGD_DHT, Otuke district.
“The VHTs were not trained on malaria. They were only trained on NTDs”. FGD_DHT,
Otuke district.
“as a district, it is hard to get information from the VHTs as data is submitted to partners
directly as they have the capacity to facilitate and link up with them and by the time we
ask for reports from them, it is long overdue. Thus we have to go partners for the
information yet it is the partners supposed to get these reports from the district.
FGD_DHT, Kyejonjo district.
The number of partners supporting the VHT programme varied across districts and regions.
Reports from the District Health Teams showed that Sembabule district did not report the
existence of an implementing partner supporting the VHT programme; Adjumani, Moyo and
Rakai districts have the least number of partners (1) and with Kampala Kyenjojo district having
the highest number of Implementing Partners. These variations may be attributed to partner
interests in particular districts and sub counties or to budgetary constraints. (Appendix 6.1).
4.4.2 Activities VHTs are Currently Implementing
Implementing partners have incorporated VHTs on several community based programs on
maternal and child health, Integrated Community Case Management, HIV/AIDS, Tuberculosis,
reproductive health, immunization, nutrition and sanitation. VHTs are actively involved in
conducting health education, community mobilization, referrals, rapid diagnostic testing for
malaria, distribution of drugs, condoms, mosquito nets and water guard and linking
communities to health facilities.
“When our partners come, we also introduce our structures to them including the VHTs.
So when they come, they use them- like recently we have been having a faith based
organization that was sub- contracted by Star- East; Caritas Tororo. It has done a lot of
community work and wanted community linkage facilitators. It took up all our VHTs to
do that- linking up the village clients who are HIV positive to the clinic, linking up services
in the health facilities to the community, and they have really done it for us”. FGD_DHT
Bukwo district.
42
Village Health Teams members have been active in playing their role of mobilizing the
community. This has been through home to home visits, village meetings and during church
events such as prayers.
“They teach us to go for family planning methods so that we can have a better life and
at least we space the children”, FGD_Community, Kamuli district.
“They are teaching people how to construct that system where you can wash hands
without touching the Jerrycan (tippy tap). I have also seen them doing health education
in church after service” FGD_DHT, Ibanda district.
The VHTs have helped to mobilize their community members to access health interventions
such as immunization, mosquito nets distribution, fistula, HIV/AIDS counselling and testing
services, conduct community health education and sensitization meetings,.
“Recently we had a team from TEREWODE organization and they wanted mothers who
had a problem of fistula and wanted to identify them and were not in town but in
villages and it was the VHTs that mobilized these mothers and (they) came very many. If
there is an activity for family planning and are using permanent methods, they mobilize.
They are not technical per se but are given some skills to mobilize people to come for
services”, FGD_DHT, Namayingo.
Village Health Teams members sensitize community members on epidemic outbreaks and how
to detect danger signs. They have also been contracted to provide edutainment through their
VHT groups to deliver health education messages at public events.
VHTs conduct community sensitizations on disease prevention strategies such as hygiene and
sanitation practices e.g. hand washing, construction of pit latrines, utensils stand, sleeping
under mosquito net and drinking boiled water.
“What I have at my home has been as a result of VHT efforts. I have managed to
construct a pit latrine, a drying rack and a rubbish pit. I never used to have any of these
things” FGD_Community, Butaleja district.
“They teach people about the dangers of dirt like not having a latrine and this has helped
people to be clean. Some years back, people did not find it important to dig deep latrines
but now they dig deep latrines of about 30-40 feet. VHTs have helped people to be clean
in their homes” FGD_Community, Mbarara district.
In addition, VHTs carry out community sensitizations on importance of uptake of health services
e.g. going for HIV tests, antenatal care and delivery at health facilities, safe male circumcision,
immunization and family planning. They equally sensitize communities on collective social
responsiveness e.g. building fences around boreholes and clearing bushes along village paths.
43
“They mobilise us to make fences for the boreholes and advise us to keep the jerrycans
used for fetching water clean” FGD_Community, Butaleja.
Due to their active roles in disease prevention, treatment, promotion of health services, their
prompt response and commitment, VHTs have earned the respect of the communities they
serve.
“Those health workers are good and we admire them and personally, I would love to be
part of them based on the way they conduct their work. When a VHT comes to your
home, and it is dirty, he or she can help you clean your place and continually advise us to
maintain hygiene in the homes” FGD_Community, Butaleja district.
VHTs identify patients in the communities suffering from neglected tropical diseases (NTD).
These include Onchocerciasis (river blindness), elephantiasis, bilharzia etc. In addition, once
VHTs have identified the sick in the communities, they ensure that they access health services.
VHTs identify and notify health facilities on the outbreaks of epidemics such Marburg fever,
Ebola, Polio, Hepatitis E and nodding syndrome.
Whereas VHTs can also provide basic treatment of some kinds of illnesses among patients in
the community, they are encouraged to refer patients with danger signs or those who present
with unknown conditions or conditions which they are unable to manage to the nearest health
facilities.
VHTs have been instrumental in the distribution of drugs in the communities to population
groups such as children under five. Such drugs are mainly deworming tablets and anti-malaria.
In addition, VHTs have been involved in the distribution of the neglected tropical diseases
drugs. Whilst it is true that the VHTs have played vital roles in distributing drugs to community
members, it is however noted that this role has been constrained by the shortfalls in drug
supply from the health facilities. This shortfall has been blamed on drug theft in some cases.
Quite often community members were being told by VHTs that there were no drugs whenever
they wanted to be given the drugs. Some VHTs are also alleged to have been selling the drugs
or only giving them to relatives and friends. VHTs have themselves also carried out
immunization activities.
“Like right now we are doing this mass polio campaign. We are using the VHTs for
immunisation and some of them are even immunising – vaccinating children”. Bukwo
FGD _DHT.
In most instances, they have contributed in terms of mobilisation of community members for
uptake of immunization services. Therefore, VHTs can be credited with ensuring their
44
functionality in regards to the role of promoting immunization services uptake in the
community.
Discussion
Implementing partners have made significant contributions to the overall implementation of the
VHT programme through the provision of financial, technical and logistical support. This support
has improved utilization of health care services provided by VHTs in the areas of immunization,
sanitation, HIV/AIDS services, antenatal care, deliveries and family planning services. However,
there is inequitable distribution of partners among and within districts. This may be caused by
the uncoordinated selection criteria of the districts of operation. This leads to inequitable
distribution of skills among VHTs. Districts with many partners may have VHTs who are more
skilled than those with few partners or none at all. This has implications on quality of health
care services VHTs deliver to the community.
The roles played by the VHTs as indicated by the community FGD data are reflective of the
content of the VHT training. The most common roles played by VHTs are community
mobilization and this is consistent with the content and requirement of the basic VHT training
guidelines. The community members are appreciative of the roles played by VHTs in health
service delivery especially in hygiene and sanitation, drug distribution, antenatal care, HIV and
family planning.
Although the Government of Uganda owns the VHT programme, VHTs pay more allegiance to
the IPs who provided them with more facilitation than government. This is reflected in the VHTs
willingness to participate in IP related projects as opposed to those for the government where
there is less or no facilitation.
4.5 Extent to which the VHT implementation guidelines are being implemented by the
Ministry of Health, the Districts and Partners (Objective 4)
4.5.1 Introduction
The VHT guidelines (2009) stipulate the modalities of the course of action regarding VHT
recruitment/selection, training, reporting and supervision. The review assessed the extent to
which the Ministry of Health, districts and the partners were implementing the guidelines.
4.5.2 Selection of VHTs
According to the MoH VHT operational guidelines (2009), members of the Village Health Team
should be selected by the community itself and not imposed by political structures and
selection should be gender sensitive. It is recommended that VHT members should be selected
45
from the communities that they will serve and that the communities should have a say in their
selection. The common practice for the VHT recruitment involves community mobilization and
sensitization by members of the District Health Team or a health worker from the nearest
Health Center; this health team member then facilitates the community to select a VHT often
by popular vote based on the agreed selection criteria. The following is the recommended VHT
selection criteria according to the guidelines:
Should be exemplary, honest and trustworthy and respected
They should be willing to serve as a volunteer
Must be a resident of the village
Should be available to perform specified VHT tasks
Should be interested in health and development matters
Should be a good mobiliser and communicator
May already be a CHW TBA, drug distributor or similar
Ideally should be able to read and write at least the local language
The assessment could only determine adherence to selection criteria on two components of
being able to read and write and community participation in selection. Findings from the study
indicate that only 4.4% of the VHTs are below upper primary, the level below which VHTs may
not be able to read and write in the local language. This shows adherence to the guidelines in
regards to selection.
As far as community participation was concerned, close to 10% of the VHTs were selected
without following the selection guidelines. They were selected by community leaders, NGOs
while others joined on their own (Table 13).
Table 13: Recruitment of VHTs
Modality of Recruitment Frequency Percent
Recruited by the community 2320 90.6
Community leader 229 8.9
Selected by the NGO 6 0.2
Just joined by myself 3 0.1
Total 2558 100
In practice, while the guidelines for selection of VHTs were adhered to in most instances, they
were flouted in others. The adherence is reflected in the community members’ participation in
the selection of the VHT through village meetings.
46
“The chairman and community in the local council one gathered and selected those that
never leave the village and they were guided on how to select the VHTs. In selecting
these VHTs, we considered those people who are always in the village, approachable and
those who have had some education. We also selected those who can take good care of
our medicine and are clean”, FGD_Community, Gomba district.
As summarized in the above extract, there was adherence to the MoH guideline for VHT
recruitment and selection in most districts. Community members were mobilized and guided on
whom to select based on their residential status, education level, inter-personal relations and
integrity. However, some Local Council leaders (LCs) were reported to have individually
identified their relatives or themselves for the VHT positions.
“People choose their relatives and friends and also LCs impose themselves into these
positions. Because of some small money and bicycles, someone wants to be both an LC1
and a VHT”, KII, Alebtong district.
We observed no significant regional variation in the selection of the VHT members. However,
the central region had 15.7% of the VHT members selected by community leaders, which
markedly deviate from the guidelines (table 14). Conversely, Karamoja region had the highest
community participation in the selection of the VHT members largely attributed to the UNICEF’s
guidance and support in this region.
Table 14: Selection of VHTs by Regions in Percentage
Selection criteria Northern
n=549
Karamoja
n=134
Eastern
n=772
Central
n=541
Western
n=562
Overall
Country
N=2558
By the
community
93.4 99.3 92.0 83.9 90.7 90.7
Community leader 6.6 0.7 7.1 15.7 9.3 9.0
Other Selection* 0.0 0.0 0.9 0.4 0.0 0.3 *Other selections included selection by IPs or self
The DHTs were instrumental in VHT selection by facilitating the process and the communities
were empowered through this process to make informed decisions in the selection of their
VHTs. The assessment therefore found that to a large extent there was adherence to the VHT
recruitment and selection criteria.
47
Discussion
The VHT selection guidelines are in place and have largely been used. This is evident in the
involvement and participation of the communities in selecting VHTs. However, a small
proportion of VHTs were not selected in accordance with the guidelines in place. This included
selection by local leaders, IPS and self-selection. This may imply that the quality of VHTs not
selected according to the selection guidelines may not meet the selection criteria such as being
able to read and write or trusted, committed to working and are permanent residents in the
community.
4.5.3 Training
VHT training includes the initial and continuing/refresher training. In the initial trainings, the
content included, among others, disease prevention, community mapping, community
registers, home visits, community mobilization, health education and referrals which is in line
with the stipulated guidelines.
A third of VHTs (34%) did not receive initial training but are working as VHTs in the districts. The
initial training is required to run for five days. The study established that the VHT initial training
time ranged between 1 to 14 days. Overall, it was established that more than half of the VHTs
were trained for 5-7 days. Among VHTs who received basic training, nearly a third was trained
for only 1-4 days.
The methodology of training has followed what is stipulated in the guidelines as it involves
more of participatory methods. These included brainstorming, group discussions, role-plays,
games, field visits, sharing of experiences, practical. Training manuals have been used to
facilitate the cascade approach. This included the VHT participants’ manual; VHT facilitators
Guide; and VHT ToT guide. These training manuals are user friendly with pictorial illustrations
relevant to the specific audience.
The MoH VHT (2009) guidelines recommend that in addition to the initial training,
continuing/refresher training should be conducted based on the health needs as defined by the
community, DHT and partners. The refresher training should target only the VHTs who
completed basic training. The study established that 60,149 VHTs received programme-
specific trainings by partners but not initial. The length of time for the refresher courses varied.
The content included: HIV and AIDS, malaria management, maternal health, nutrition, record
keeping, family planning, integrated community case management (ICCM)
In this assessment, VHTs were asked the number of additional trainings they have received.
They reported the numbers ranging between 1 and 30. On average, VHTs had generally
48
received 6 additional trainings after the basic. Whereas these trainings have been carried out,
they have not been as regular in some of the districts. In fact, the call for more regular refresher
trainings was expressed quite often in the different districts such as Pader, Kamuli,
Nakapiripirit, Kaliro, Tororo, Kapchorwa, Mukono, Sembabule, Kalangala, Maracha, Nebbi,
Hoima, and Kamwenge among others.
Discussion
Whereas the guidelines and training manuals to support VHT trainings are in place, nearly a
third of VHTs have not received initial training. This may have been as a result of a number of
factors such as; lack of funds by districts to conduct initial trainings, self-appointed VHT
members and selection by local leaders and by IPs, against the guideline. Such tendencies to
select VHTs without the community involvement could have been due to lack of supervision by
the districts. Consequently, a substantial number of VHTs may lack adequate skills to perform
their duties.
The one third VHTs who received initial training in only 1-4 days imply that the training duration
according to the guidelines was flouted. This may have therefore lowered the quality of the
training conducted, as the training period is too short to equip the VHTs with the necessary
knowledge and skills. Though the training period of five days of basic training is in the
guidelines, it is however too short for the trainees to comprehend all the content and apply it.
Besides, the varying education levels of VHTs affect their ability to comprehend the content of
the training.
Programme-specific trainings by IPs are not harmonized in terms of standardized materials,
content, duration and methods. This clearly is not in line with the guidelines on refresher
training.
4.5.4 Supervision
For the purpose of this assessment, supervision refers to the oversight function of the district
and lower local governments over the VHTs to ensure that they execute their roles in the
guidelines.
4.5.4.1 Structure of supervision
Only 70% of VHT members reported having been supervised. Health Assistants, In-charges of
health centers and Parish VHT supervisors, and some by NGOs and CDOs are reported to have
conducted the VHT supervision. However, there were no reports to support this. The quarterly
review meetings at the district and health centers are usually viewed as supervision activities.
49
However, there was reported on-spot supervision conducted by district leaders including the
Resident District Commissioners, District LC V Chairmen as well as implementing partners.
Routine supervision is also carried out by the in-charges of health centers and health assistants
at the health centers and within the community.
“We have been having review meetings where the VHTs are met at the health centers
and we give them feedback. Then also we have been giving them support supervision
where the health worker at the health facility (in-charge) go and supervise them”.
FGD_DHT,Buliisa district
At the national level, support supervision was found to be inadequate due funding constraints.
In some instances, development partners have taken lead in VHT supervision. The districts and
Ministry of Health were perceived as less involved in VHT supervision even when they own the
VHT programme.
“The Ministry of Health has also relaxed towards follow up of VHT activities in that they
have left it into the hands of partners”, KII_ partner_Kiboga district.
“When we don’t initiate the supervision program, the district does not do it because they
claim not to be having resources to conduct monitoring and supervision. This in other
words tells me that these VHTs have been left in the hands of the development partners
yet it was initiated by the Ministry of health as the government”, KII_partner,_Kumi
district.
The Ministry of Health recognizes the problem of lack of supervision as stated in the quote
below:
“Quarterly support supervision- this is not happening. It happens only when funds are
available- this was last done three quarters(s) ago”, KII_MoH
Supervisors of VHTs according to the MoH (2009) VHT guidelines should come from HC II and
HC III to which the VHTs are attached or Community Development Officers (CDOs) or Health
Assistants or Health Inspectors.
However, in addition to these listed supervisors, in this study we identified that VHTs are also
supervised by other structures that include the DHTs, Local councils, CDOs, VHT Coordinators,
Peer Supervisors and IPs deviating from the guidelines. The selection of supervisors largely did
not follow the guidelines (table 15)
“At grass roots level, we mobilise and actually visit activities that VHTs perform. Our
local council III also helps as supervisors. They supervise VHT activities and report to us
accordingly”, KII_ Bukedea District.
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Table 15: Selection of VHT Supervisors
Selection criteria Frequency Percent
No criteria 24 22
One Criterion 36 32
Two criteria 27 24
Three criteria 18 16
Four criteria 6 5
Many of the district leaders reported carrying out indirect but not much of direct supervision of
the VHT activities. Indirect supervision involves mandating the DHO/DHT to supervise the VHT
activities and to report to the top district leaders such as Chief Administrative Officers (CAOs),
LC.V and the Resident District Commissioners (RDCs).
“Personally, I supervise the VHT activities and even monitor them. As a district, we have
our technical people the DHT, the political wing and the people in security all of whom
monitor and supervise the activities of VHTs in different ways”, KII_ Kumi district.
“When I go down to the villages, I ask them how they are working and even check their
reports and when I go to monitor other partners work like Boreholes, the element of
sanitation is common and the VHTs are key, they are always elected as water source
committees for the boreholes. So in that way, I supervise the VHT work”, KII_ Apac
district.
At the community level, VHT supervision has also been undertaken by Peer Supervisors, the
local Council I chairpersons and the health assistants. Peer Supervisors are VHT members who
support fellow VHTs on writing reports especially due to illiteracy among some of the VHTs.
In Karamoja sub-region where illiteracy is very high among the VHTs, Peer Supervisors have
been used to support the VHTs in documentation of the VHT activities such as in report writing.
“We created the peer supervisors to help illiterate VHTs to document reports. The peer
supervisors work as supervisors to check what VHTs have done on issues of sanitation
whether the community members have latrines”, FGD_DHT, Kotido district.
“A Peer supervisor supervises VHTs and the peer supervisors are being supervised by
Health Assistants and Health Assistant are being supervised by VHT Focal Person. During
support supervision stock taking is done and data management tools are checked”,
KII_Partner, Gulu district.
Table 16 below indicates that most of the VHTs (46.5%) were supervised by the health
assistants and 33.6% were supervised by health centre in-charge. This is line with the
guidelines that stipulate that the central figure in supervision is a designated individual from
the first referral level who has contact with VHTs on a regular basis. VHTs are directly
51
supervised and report to the health centres through the Health Assistants as indicated in the
MoH (2009) VHT guidelines on supervision where the VHTs are to be supervised by the Health
Assistants. In communities where IPs exist, it was found that the IPs conduct VHT activity
supervision through the health assistants. However, some VHTs (7.6%, 3.4%) were supervised
by NGOs and CDOs respectively which is also not in line with the guidelines.
Table 16: Supervision of VHTs
Supervisor Frequency Percent
Health Assistant 752 46.5
In charge of the health centre 543 33.6
Parish VHT Supervisor 521 32.2
Direct supervision by NGOs 189 11.7
Direct supervision by CDO 87 5.4
Discussion
The assessment revealed that VHTs are supervised at the health center IIs or IIIs or IVs and at
district level as stipulated in the guidelines. However, there were no supervision check lists and
reports ascertained. Supervision of the VHTs was hampered by lack of resources including
funds, transport and technical capacity for supervision.
Supervision was undertaken mainly by Health Assistants, in-charges of health centers and
Parish VHT supervisors and LC I Chairpersons as well as by NGOs and CDOs. The selection of
VHT Supervisors was not rigorously followed in 95% of the cases. It was however difficult to
ascertain whether these various supervisors and the VHT members themselves understood
what supervision entails.
Therefore, the lack of supervision tools, reports and apparent understanding of what
supervision entails leaves gaps in determining whether the supervision reported to have been
carried out was effective. The lack of reports suggests that supervision may not have taken
place. The non-adherence to the VHT Supervisors’ selection guidelines therefore compromises
the quality of VHT supervision.
4.5.5 Reporting by VHTs
The assessment found that VHTs fill in their registers, collate data and share their reports with
the health centers where they are attached. This is illustrated in narratives from two focus
groups below.
“The 5 VHTs at village level sit and compile their monthly report and from there a
representative from the village meets the parish supervisor with other representatives
52
from other villages in the same parish, they compile the parish report. Then the sub-
county supervisor calls the parish supervisors and they sit with their parish reports and
compile one report for the sub-county which is later brought to the HMIS focal person at
the district. A copy is sent to the partners. So the HMIS person sends the report to the
Ministry and this is always done on time”, DHT FGD Namutumba.
“VHTs make monthly reports to health assistants at the facilities they are attached to
then the health assistants take initiative to report to Plan Uganda and sometimes we
support the health team during supervision”, KII_Partner, Plan Uganda.
Although there is a hierarchical reporting mechanism right from the village through the parish
(health centre), sub-county to the district level exists , some district such as Otuke, Sheema and
Buhweju, there was practically no reporting due to the absence of a reporting format/tool and
lack of training. The districts reported that they were awaiting trainings in order to start
reporting.
“There are no reports because we are still waiting for a format to train and report”,
FGD_DHT, Buhweju.
The mTrac reporting system is a sms-based reporting system that combines both statistical
data and some narrative. It is a government led initiative to digitize the transfer of Health
Management Information System (HMIS) data via mobile phones In Gomba district for instance, it is
used to accompany the paper-based reporting system.
“They (VHTs) report weekly through MTRAC. They report to the parish co-ordinator in
the monthly meetings held at (the) parish headquarter”, FGD_DHT, Gomba district.
The frequency of reporting varied among IPs contrary to the quarterly reporting required by
MoH as stated by Mpigi DHT. The most common frequency of reporting for most VHTs is
monthly (as outlined in the guidelines) and quarterly. However, in some few cases, weekly
reports are made.
“They report to the programme, let me say, Malaria Consortium. If they say they want
to report every month, they bring the reports monthly to the focal person who will have
been selected by that programme to do that. Mildmay may be working with them on HIV
Clinics and they report weekly. PACE is working with them to mobilise people for the
positive living services, they report monthly. So it depends on the programme they are
involved in”. FGD_DHT, Mpigi district.
It was also established that some districts were defaulting on their reporting roles to the
Ministry of Health. This is because the VHT focal persons in such districts were failing to submit
reports to the Ministry of Health.
53
“Some focal persons do not share reports with the centre”, KII_MoH
4.5.6 Reporting tools for VHTs
A sample of a VHT register, Kabale district, 29-11-2014
The study established that the tools used for reporting by VHTs include registers, summary
sheets from HC IIs and districts and computerized data base in which data are entered into a
spread sheet by Health centre staff.
Paper-based forms for reporting were found to be the most commonly used in most districts.
Reporting tools were mostly found with implementing partners. The tools were tailored to suit
the programmatic priorities of each respective implementing partner.
“We give VHTs tools to use during field activities and then use the tools to evaluate the
programme, for example, the number of mothers referred and tested and then those that
have obtained nutrition counselling are obtained from the outreach tool”, KII_partner,
Namutumba district.
54
The assessment revealed that IPs such as World Vision and, districts such as Butambala,
Bukomansimbi, Gomba, Moroto, Kyankwanzi, Kiboga and Wakiso have adopted and are using
mTrac sms reporting system.
Table 17: Level of VHT Report Submission
Report submitted to: Frequency Percent
Health centre II 977 49.9
Health centre III 805 41.1
Health centre IV 123 6.3
District 21 1.1
Partner 32 1.6
The vast majority of VHTs submit their reports to Health center II and III. A few VHTs submit
their reports to the districts and implementing partners (table 17).
Discussion
The assessment showed a hierarchical reporting from the village through the parish (health
centre), sub-county to the district levels. However, in some districts such as Otuke, Sheema and
Buhweju, there was practically no reporting due to various reasons including the lack of tools
and lack of training. The study however did not determine whether the hierarchical reporting
existed in every district. The absence of reporting tools and training on reporting constrained
reporting and suggests the need for capacity development in this area.
Various reporting formats and tools were used including mTrac. However, paper-based forms for
reporting were found to be the most commonly used in most districts. Reporting tools were
mostly found with implementing partners. This implies that reporting took place based on
availability of tools in settings and programmatic priorities of implementing partners. It may also
imply that VHT supervisors at health center levels could only exercise limited supervision on
VHT reporting. The inadequate reporting tools, existence of various implementing partners and
reporting formats coupled with low education level of some VHTs therefore suggest that there
was irregularity and poor quality in reporting.
4.5.7 Coordination of VHT programme
The assessment found that the DHOs have the overall mandate for coordinating the VHT
programme within the district. They specifically assign a district VHT focal person to be
responsible for VHT coordination, training, monitoring and supervision. The District Health
Educator (DHE) was designated that role in most districts. However, coordination meetings
55
and support supervision at lower levels have been irregular. Even at the national level,
coordination was recognised as a gap in the VHT programme.
“There is a national committee that should meet quarterly but this has not been regular.
These meetings incur costs and therefore need funds for the meeting”, KII_MoH
“Coordination became poor, there was no steering committee in the MoH, we did not
know who was training and where, there was weakness at the central level for effective
training, monitoring and evaluation; there was no effective leadership at the Ministry of
Health”, KII_MoH
“Coordination is also a problem in some areas; you don’t find health assistants who
should be in touch with VHTs in terms of supervision”, KII_Manafa district
Discussion
There are VHT operational guidelines in place to support coordination mechanisms. However,
poor coordination has arisen due to human resource and financial constraints mainly at
national and district levels. The irregularity of the quarterly national steering committee
meetings could have led to increasing gap in VHT coordination with and within districts. Lack of
coordination led to poor supervision of IPs and their activities.
4.5.8 Referrals
For a functional VHT programme, an efficient referral system should be in place to determine
when a referral is needed, the logistics plan in place for transport and funds when required and
finally a process to document and track referrals. The Ministry of Health guidelines identified
two levels of referral.
Routine referrals: non-urgent conditions include:
All conditions without danger signs for which the VHT has received training/instructions
to when and where to refer
All conditions without danger signs for which the VHT has not received specific training,
or if the VHT does not have the necessary medications
Routine outpatient or outreach referrals for Immunisation, Antenatal Care, Post-natal
care (Mother and Infant)
Referral of children >6months with mid arm circumference (MUAC) yellow.
All conditions which require rehabilitation e.g. after injury, patients with leprosy.
Clear guidance must be given to VHTs on where to refer non urgent cases.
Emergency referrals:
This should be to the nearest health facility. These include conditions that require urgent
treatment such as:
56
All Pregnant women (obstetric emergencies), new-borns or children or other person
with danger signs including red on the MUAC strap.
Anyone with sudden recent loss of visual acuity, or a painful red eye or recent inability
to close the eye
Accidents or injuries.
This assessment established that VHTs have played key roles in identifying and referring under
five children and sick community members to the health facilities.
“VHTs link communities to health centres through networking and referral systems for
diseases like HIV/AIDS, maternal and reproductive health problems, for antenatal (care),
immunisation”, FGD_DHT Namayingo.
“They move in the community and give health education thus they come in contact with
those who have had cough for like two weeks and refer them. T.B, HIV patients who are
on treatment are also referred. They also refer clients with diseases which they have
never had prior training on or if he/she doesn’t have the necessary medication for that
particular disease”, KII_In-charge HC III, Kisugu.
VHTs also accompany sick patients to health facilities such as pregnant mothers, youths and
dog bite patients as were reported in Bukwo district.
Over all, VHTs have been trained on referral forms and are actively involved in the referral of
patients to health facilities. However, in some health facilities, some health workers have had
negative attitudes concerning the VHT role of referring patient’s as explained in Namutumba
district. This concern was voiced in Soroti, Kween, Nebbi, Mubende and Gulu districts.
“Some health workers have failed to understand the strategies of VHTs. Some even
demotivate them by asking them, ‘who are you? What did you study? And even throw
away the referral forms”, FGD_DHT, Namutumba district.
“Some health workers think VHTs want to take their work so they do not work hand in
hands with VHTs. They do not appreciate VHTs”, FGD_DHT, Mubende district.
This negative perception could be due to the lack of sensitization of health workers on VHT
roles and or coordination amongst VHTs and health workers. Some community members also
have similar negative attitudes towards VHTs.
“Some communities don’t understand VHT roles and thus chase them away from their
homes. Someone says, I know you, what do you also know about health, go away. They
lack recognition”, KII_Bududa district.
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Nearly 9 in 10 VHTs (91.4%) referred clients using the common approaches of filling out the
referral forms (77.8%) and writing in the book (22.2%). VHT-members following up of the
referral to the health facilities were almost universal (97.2%). The most commonly reported
referred conditions were pregnant women (42.5%), under-fives (31.8%) and clients on long-
term treatment (17.0%) as shown in table 18. Facilities usually patients where patients are
referred were government health (97.4%) or private (2.6%) health.
Table 18: Clients Referred by VHTs in the Last Six Months
Support Frequency Percent
Pregnant women 1108 42.5
Post-natal mothers 227 8.7
Clients on long term treatment 444 17.0
Under five 829 31.8
Discussion The assessment established that most of the VHTs referred clients to health facilities. However,
the assessment also found out that Health workers sometimes did not respect referrals made
by VHTs. This emanated from the fact that VHTs are considered people of low education who
are not competent in disease management as they are not medical personnel.
It was not clear whether referrals made by VHTs were effective as well as recorded by the
service providers at the health facilities. In addition, the assessment found that there were
other concerns that affected effective referral such as lack of medicines in and transport
means to health centers.
4.6 Approaches for Motivation Mechanisms and arrangements (Objective 5)
4.6.1 Volunteerism in the VHT programme
VHTs are known or perceived by the district leaders as volunteers and non-government
employees. Thus they are not supposed to receive salary. This concept of volunteerism has been
a demotivation factor as the VHTs now think that they should be paid for their services. This has
attracted the attention of different stakeholders who think that VHTs should be paid.
“The VHTs have been voluntary, voluntarism can’t continue forever”, KII_MoH
“They will begin the work very well but they will see themselves not gaining because of
volunteerism within the shortest time period. So they will also start comparing
themselves with others and the work they do and say we are doing a lot of work for
these people for nothing. And then they relax”, FGD_DHT, Moyo district.
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“Government should motivate VHTs, they should be given some monthly allowance”,
FGD_Community, Hoima district
“Volunteerism is a problem. It has been over taken by events. It first worked because
they first expected to be salaried employees over time, and other incentives such as
scholarships and absorption in the civil service”, KII_MoH.
Due to the ineffective roll out of the minimum package for VHT motivation mentioned above,
some of the VHTs have lost enthusiasm and dropped out of the programme. However, their
replacement was a problem as districts lacked funds to train the new recruits in their roles.
“Their contribution is fundamental. They are doing a good job and if we had resources,
we would pay them. They are doing what we could not do in their villages”, KII_Mbale
district.
4.6.2 Motivation of VHTs
MoH has defined this minimum motivation package for purposes of identity, cultivating a sense
of achievement and recognition (MoH, 2009). Motivation entails instituting and reinforcing
mechanisms that recognise and appreciate the contribution of VHTs to their communities.
The 2009 Ministry of Health operational guidelines recommend a minimum package for VHT
motivation (Box 1).
Box 1. Incentives for VHTs in Uganda
Source:
MOH Operational Guidelines for establishment and scale up of village health teams
To motivate VHTs, the districts and IPs have used a combination of monetary and non-monetary
incentives. The most commonly used motivation were provision of allowances, official
recognition, capacity building, and provision of supplies, medicines and equipment to facilitate
VHT work, certificates and income generation activities.
Basic requirements to carry out VHT function (Standardised VHT uniform, ID, Standardised bag and kit using MoH VHT logo. Lunch and travel allowance whilst carrying out outreach and visits to health centre).
Health worker supervision and mentoring – technical support
Activity and performance related incentives
Recognition by Authorities and their own communities-
Advocate and support for VHT to access Government programs, income generating schemes and other microfinance and credit schemes
Community reward – such as community digging, seeds, livestock
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Monetary Incentives: Financial incentives have been provided in the form of allowances mainly
given during activities or events for transport, lunch provision and bicycle maintenance.
Partners provided forms of motivation that included transport and feeding allowances.
The allowances ranged from as low as 2,000 Ushs to 25,000 Ushs per activity. On the other
hand, some of the allowances are provided on monthly or quarterly basis ranging from between
25,000UGshs to around 100,000 Ushs. However, it was not possible to establish the proportion
of VHTs who were getting allowances.
Financial support has also been provided to VHTs in the form of education support to the
children of VHTs who cannot continue going to school because of lack of school fees VHTs have
been encouraged to form their own SACCOs and VHT associations for income generation. In
some districts, VHT associations have been contracted to provide edutainment from which they
can earn some payments. Some districts rely on implementing partners to provide financial and
other forms of motivation to the VHTs.
“The district simply relies on NGO support. But as a district, there is no budget for VHTs
which makes it impossible for the district to fund VHT activities. The district cannot even
afford to print t-shirts to identify them…NUHITES also uses the VHTs and currently it is
the only NGO that actively supports them”, KII_Nwoya district.
“Motivation comes from partners through the district. While Yumbe district is really
willing to give their total support to VHTs, the only challenge is lack of fund from the
District” KII_CAO, Yumbe district.
“We train VHTs, give them transport refund when they come for any activity, feed them
and provide VHTs with accommodation also so that they don’t spend their money”,
KII_LC.V, Nwoya district.
Non-Monetary incentives
Logistical forms of motivation have been provided either through MoH support to the districts
or through IPs operating in the districts. The Logistics provided to the VHTs included among
others, bicycles, t-shirts, torches, gum boots, rain coats, lunch and transportation as well as
hand bags.
“The district has no specific budget for the VHTs but we have given them bicycles to
facilitate their transport. We also give them t-shirts and small allowances when new
projects are brought to the district by the different partners” KII, Lamwo district.
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A sample of VHT T-shirt, Kibuku district, 10-12-2014
Gum boots and umbrellas for VHTs in Butalejja district, 26-11-2014
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In some districts such as Kaabong and Soroti, the community members reported having
provided food to VHTs while conducting community mobilization.
“Sometimes, I cook tea for VHTs or roast ground nuts for them as they pass around while
on mobilization tours. I have ever given one a hen after making for her orange juice
because she was hungry”. FGD_Community, Soroti district.
In practice, the moral support have majorly been in the forms of appreciation by words of
mouth, giving titles to VHTs e.g. super VHT, priority in accessing health services, public
recognition on mass media or at public events and encouragements.
“We always tell them that they are the best at what they do” KII_Otuke district.
“We recognise them on national occasions such as the Independence Day. We give
speeches in honour of what they do for the community and appreciate them”, FGD_DHT,
Pader district.
“We give them simple recognition. We appreciate them at the end of the year e.g. we
write an appreciation certificate so as to boost their morale. Also we recognize them
during public functions and this makes them feel respected”, KII_Mpigi district.
“The district encourages the VHTs to form groups and some of them have benefited from
government programs like poverty alleviation fund” FGD_DHT, Masindi district.
DHTs from Nakasongora, Kamuli, and Luwero and Lamwo districts reported that priority is given
to patients referred by VHTs at health facilities which motivated the VHTs in their work.
“…VHT is the core. For us to improve on maternal child health, we needed really to have
functional VHT. And for us to have functional VHT there must be means to motivate
them because that is where normally problems will come. So we should have really
something in place right from the ministry of health since they are part of the system. To
make the whole system function, there must be some budget, much as they are many
there must be a budget maybe for monthly meetings. And then, they don’t need much
then we can get something once in a while maybe like T-shirts yearly to motivate them.
Every year you can give them a T-shirt, the way we are doing it to LC1’s, like every year
they get like 120,000 if we really want to improve the health system”, FGD_DHT, Kitgum
district.
Other non-monetary forms included:
Capacity Building
Various ways of capacity building were identified. These included:
62
Support supervision, Trainings, Mentorship, Exchange visits, meetings, involvement at
Health facilities
Feedback from referrals from health facilities
Participation in data collection & surveys
“Refresher trainings by the health department, DHI office and district partners. There is also
a current support from Amatheone-Agric, an NGO which has come up to support famers but
they are interested to link-up with the VHTs to provide health services needed to their
potential farmers, mainly in building the capacity of the VHTs to help in the hard to reach
areas. Amatheone-Agric support is directly to farmers and may support VHTs with transport
but not money”, KII_Nwoya district.
We note that while these various forms of motivation have been provided to the VHTs, they
have largely been irregular and none uniform as have been the case with financial and logistical
forms of motivation. The motivation also varies from IP to IP and from district to district.
“Incentives were not well defined. It would depend on the donor or government
programme. The incentives were not consistent; the system of distributing incentives
was not organized. Turn over became so much and drop outs were very high”, KII _MoH
“The motivation is lacking, (there are) no standard incentives that are given; they vary”,
KII_Partner, Pathfinder.
“There is Mildmay Uganda, Profam, TASO and also Uganda Care. These IPs work in some
regions. But most of the time you find it is the same VHTs that are picked repeatedly, so
they are very motivated while others are not. Every partner wants a VHT that is literate
and can write a report, not starting from scratch to train them”, FGD_DHT, Masaka
As such, the irregularity, non-uniformity and variance in form and substance of motivation have
been de-motivational other than motivational to some of the VHTs. The result of this has led to
drop out and inactiveness as well as poor relations among the VHTs. Thus to some extent, this
fragmented way of motivation has to some degree impeded the functionality of VHTs.
“Different rates of facilitation of the VHTs i.e. Strides facilitated them with 12,000 UGX
while the Local Government was giving them 6,500 UGX. They tend to run to partners
who give better facilitation. Since not all of them are taken on by partners, they end up
dropping out of the system”, FGD_DHT, Kasese district.
“..bicycles given did not go to all VHTs; only one VHT in every village. That also caused a
challenge because it demotivated the other VHTs. A coordinator was almost beaten
sometime. He had to come up with a list of members who had not got bicycles”,
FGD_DHT, Ibanda district.
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While various kinds of logistics were provided to facilitate VHT work such as torches and
bicycles, in some instances they were reported to be of poor quality, with no spare parts.
4.6.3 Suggested VHT motivation mechanisms and arrangements
Various VHT motivation mechanisms were suggested by the community members, VHTs,
partners, district health teams (DHTs) and district leaders.
1. Establishing a standardized and regular financial way of motivating VHTs
2. Recognition and appreciation of the contribution of VHTs by both the central and local
governments
3. Capacity building in the form of educational short courses, trainings and mentorship
4. Provision of a conducive working environment for the VHTs in terms of
a. Ensuring cordial relationship between VHTs and the formal healthcare workers
b. Provision of essential supplies such as uniforms, bags, gum boots, umbrellas, identity
cards, bicycles, among others
c. Provision of special rewards for VHT work
5. Provision of planned and well executed regular supervision
6. Engaging the VHTs in economic empowerment activities such as savings and credit
cooperative societies (SACCOS)
7. Ensuring safety and security of VHTs especially during epidemic outbreaks such as viral
haemorrhagic fevers, e.g., Ebola and Marburg. This includes provision of protective
gears
8. Provision of appropriate transport means for hard-to-reach areas such as hilly and island
areas
9. Involvement and engagement of VHTs in the national activities e.g. National
Immunization Days (NIDs), Child Days Plus (CD+)
Discussion
The provision of monetary and non-monetary incentives to VHTs contributes to motivation and
retention of VHTs. While the VHT Operational Guidelines stipulate the various forms of
motivation for VHTs, it does not explicitly describe how these should be equitably distributed
and who should provide these incentives. For instance, the financial forms of motivation did not
have the educational level required and yet government does not pay workers without formal
education. The minimum package did not stipulate a salary but a reimbursement of costs for
transport or for meals. In addition the MOH guidelines did not provide clarity on what
constitutes activity and performance-related incentives.
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While there are economic and social benefits of volunteerism, maintaining the VHTs to perform
their functions can be eroded over time if some basic needs are not met. Some VHT who
volunteered had high monetary expectations and if these were not met, some dropped out of
the VHT program. Some of the materials provided were just tools but were not meant for
motivation. Although those materials were meant as materials to facilitate VHT activities, they
provided motivation to VHTs. The study found that there are certain things beyond what was
thought as motivation to VHTs. Qualitative data showed that there is an overwhelming demand
for a harmonized and regular financial form of motivation for the VHTs.
The various ways of motivation are not uniform thus creating disharmony at the district level
and among the VHTs hence making coordination ineffective. Although the MoH, Partners and
IPs are providing different kinds of motivation, there is no system for tracking the different
motivation packages and support for VHTs hence there is need for harmonizing motivation
approaches and packages to address these anomalies.
Various ways of motivation of VHT members as seen above were suggested by different
stakeholders including VHT members. The proposed idea to establish a standardized and
regular form of financial forms of motivation to VHTs calls for the need to undertake a proper
planning to prepare for it. Government and its implementing partners will need to consider the
sustainability of these forms of motivation and their implications on the number of VHTs in
place.
4.6.4 Existing equipment and supplies for VHT
Forty three percent (43%) of VHT members reported possession of supplies and equipment for
use in their operations (Fig 5). An almost equal number reported possession of some of the
supplies and equipment needed to perform their duties. However, it should be noted that the
number of VHTs that reported possessing all the supplies and equipment was less than half of
the total sample.
Fig 5: Possession of supplies and equipment
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The results of assessment indicate that VHTs possessed more of material supplies and
equipment than medicines/drugs (Table 19). Supplies and equipment such as registers, badges,
t-shirts, bags and bicycles were possessed by more VHTs compared to drug related supplies
such as Coartem, ORS and NTD drugs as well as family planning supplies such as condoms.
Table 19: Supplies and equipment possessed by VHT members interviewed
Supplies and Equipment Frequency Percent
Badges, T-shirts, Bags 1401 65.3
Register 1394 65.0
Bicycle 1206 56.2
Report book 770 35.9
Condoms 611 28.5
ORS 418 19.5
Amoxicillin 371 17.3
Zinc 338 15.8
Coartem 316 14.7
NTD drugs 295 13.7
Respiratory timers 199 9.3
RDT kit 186 8.7
Gloves 183 8.5
IEC materials 154 7.2
Mobile phones 129 6.0
Identity cards 57 2.7
Tippy tap materials 32 1.5
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Solar chargers 28 1.3
Wrist watches 23 1.1
The majority of the VHT members interviewed kept their supplies in wooden boxes. They
reported that this was one of the safest ways to keep the supplies.
Discussion
Whereas a number of equipment and supplies have been availed to VHT members, they appear
to have been more focused on the health promotion and community mobilization roles of VHTs
but not treatment roles. This situation may imply that some of the treatment needs of the
community members cannot be adequately addressed by the VHT members due to stock outs.
4.7 Functionality of the VHT Programme (objective 6)
Functionality of the VHT programme was assessed at four levels: national, district, community
and individual VHT members. The study defined VHT programme functionality at national and
district levels as the capacity of the Ministry of Health and district health teams to plan, manage
and supervise VHT activities at national and district levels. At community level, functionality
was defined as the frequency of interaction between the VHT members and the health facility
to which they are attached, the existence and knowledge about VHTs by the community
members and the benefits that accrue to the community as a result of the VHT programme.
At individual level, functionality was defined as the capacity and practice of the VHTs to perform
duties assigned to them in line with the guidelines. Four indicators were used to assess
functionality at individual level that includes participation in coordination meetings, reporting,
referrals and supervision.
4.7.1 Functionality of the VHT programme at national level.
At the national level, functionality was assessed using six indicators that include; policy
environment, investment, governance, coordination, supervision and training.
4.7.1.1 Policy environment
The concept of VHT was conceived and included in the second Health Sector Strategic Plan
(HSSP 2000 – 2005). The VHT concept evolved from the WHO Primary Health Care Framework
to optimize health services to communities through community health workers.
In the Health Sector Strategic Plan, the VHT constituted the health centre I with no formal
physical structure. The role of the VHTs was to mobilize communities and carry out health
promotion. The role of the Ministry of Health was to coordinate training and provide guidelines
and information. Although some policy instruments refer to community health, there is no clear
policy that addresses VHTs. The lack of harmonization in motivation, trainings, and coordination
67
is a result of the lack of clear policy which explains how each of these aspects should be
operationalized.
4.7.1.2 Investment in VHT
The Government of Uganda made some efforts to invest in the VHT programme since its
creation. This is reflected in the allocation of funds to the VHT programme. Over time, the
Ministry of Health has provided a budget for VHT implementation. However funding for VHT
programme has been declining leaving the partners to fund most of the activities.
“There is a budget line since the creation of the VHT strategy. However funding kept
reducing from about UGX 800 million per year at the start of the programme to less than
UGX200 million per year in the last two years. The Central funding allocation is to train
VHTs, coordinate and supervise VHTs. The low funding thus constraints these roles”,
even the little money allocated is never accessed KII_MoH.
The assessment established that the money released by government in a financial year to train
VHTs in the country is not sufficient to train VHTs even in one district. As of January 2015, the
VHT coordination office had not accessed any money for VHT implementation for the financial
year. However, the government has working arrangements that allow partners to contribute to
the VHT programme. The partners are supposed to facilitate district staff to conduct VHT
activities. Various partners have contributed financial, logistical and technical resources to the
VHT programme. These partners include, among others, the UN Agencies such UNFPA, UNICEF,
WHO, UNDP, etc., World Bank, Implementing agencies such as Pathfinder International, Plan
International, World Vision Uganda, PACE, Marie Stopes, AMREF, AVSI, etc. (Appendix 6.2).
The extent of investments by partners into the VHT programme was reported to be significant.
However the total package of partner specific support could not be determined by the
assessment. They provide financial support annually to various organizations to implement VHT
activities. Such support is used to conduct training, logistical supplies, supervision and
motivation.
4.7.1.3 Governance
In 2014, the VHT section of Ministry of Health was separated from health promotion and
education division and made answerable directly to the Commissioner of Community Health. A
coordinator was put in place to coordinate the strategy at national level. The coordinator
reports to the Commissioner, Community Health. The Commissioner reports to the Director
Clinical and Community Health. The Director Clinical and Community Health then reports to the
Director General. This hierarchy is in place and functioning.
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4.7.1.4 Coordination
There is a national VHT coordination committee at the MoH comprising of Ministry of Health
staff, UN agencies and the major implementing partners. The committee is mandated to meet
quarterly. The functions of the committee include; reviewing of VHT technical guidance,
information sharing by implementing partners, and getting to know who is doing what in the
VHT strategy.
The assessment indicates that this committee does not meet regularly as mandated. For
example, since February 2014, the committee only met once in November 2014. The
coordination office is not facilitated in terms of personnel and facilities to ensure regular
meetings.
The assessment established that there though there is a revised VHT strategy (2011), it has not
been rolled out to the districts and to the partners. The districts still rely on the 2009 draft
guidelines.
4.7.1.5 Supervision
The Ministry of Health is mandated to supervise the implementation of the VHT strategy in the
country. The Ministry is also required to supervise implementing partners in terms of the
activities and how they implement them. However, the assessment results indicate that due to
lack of funding and inadequate personnel, such supervision has not been regular. For example,
in the financial year 2014/15, no funds have been accessed for supervision.
4.7.1.6 Training
According to the MoH, ToTs have been conducted in all the districts apart from Kampala
district. During the ToTs, district trainers are trained who in turn train VHTs. Most of the ToTs
were conducted in the first ten years of the programme. However, due to financial contraints,
the district trainers have not conducted basic training to all the VHTs. It could also be that those
VHTs without basic training are those who were selected outside the selection guidelines.
Discussion
Lack of funding is a major challenge to the VHT activities at national level. As a result,
coordination, and supervision of VHT activities have not been adequately done. Training of
VHTs has not been completed in all the districts as a result of lack of funding. Lack of personnel
in the coordination office has created a huge gap where the national coordinator is expected to
do all the coordination work.
The MoH does however have other opportunities for supervision such as the Area Team
supervision where VHT activities have been supervised but this is also irregular due to
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inadequacy of funding. Area team supervision is integrated health supervision in the Ministry
of Health. The team looks broadly at broadly at health service provision and is under the
mandate of Quality Assurance Department in the Ministry of Health. Overall, at national level,
the VHT national coordination office is poorly facilitated to enable it efficiently implement the
strategy as stipulated in the guidelines.
The lack of policy to guide implementation of the VHT strategy has complicated the operations
of the programme in terms of adequate funding, supervision and coordination. The lack of
coordination has left gaps in the programme. For example, the MoH has failed to roll out the
revised strategy (2011) and this has left districts relying on the draft one of 2009.
4.7.2 Functionality of the VHT programme at district level
Functionality of VHT programme at district level was assessed using data generated from the
interviews with VHT focal persons. Functionality was based on responses to the core areas of
recruitment, training, coordination, supervision, financing and documentation. The core
indicators were: guidelines for recruitment of VHTs, availability of active VHT trainers and basic
VHT training. In addition, coordination and supervision indicators were weighted more than the
other indicators with each having a maximum of four points.
As shown in Table 20, most of the districts (80%) that conducted the initial training for the VHTs
were able to follow the guidelines for recruitment of VHT. However, only two-thirds of the
districts were able to conduct VHT initial training and had active VHT Trainers. Although 44% of
the districts reported supporting VHT activities financially, less than 20% of the district
committed funds in the district budget. It was unclear if the funds committed in the budget
were later disbursed for VHT activities. Regular and consistent coordination meetings were held
in only 40% of the districts.
Table 20: Indicators of VHT Functionality
Indicators of functionality n Percent
Selection following guidelines
Yes 96 84
No 15 13
Missing 3 3
Conducted VHT TOT
Yes 95 83
No 16 14
Missing 3 3
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Have active VHT Trainers
Yes 72 63
No 35 31
Missing 7 6
Ever conducted Refresher Courses
Yes 78 68
No 32 28
Missing 4 4
Districts funding VHT implementation
Yes 50 44
No 59 52
Missing 5 4
District that allocated funds for VHTs in their budget
In Budget 18 16
No Funds 92 81
District that conducted Coordination Meeting
Yes 70 61
No 37 32
Missing 7 6
Regularity of Coordination Meetings in the last I year
None 39 34
1 meeting 15 13
2 meeting 16 14
3 meetings 12 11
4 four or more 32 28
Discussion
Although the majority of the districts followed the guidelines in recruitment (84%), carried out
ToTs (83%), has active VHT trainers (63%) and conducted refresher training (68%), the VHT
programme is lacking district funding thereby making it less functional in coordination and
supervision activities.
4.7.3 Functionality of the VHT Programme at Community Level
A majority of communities interviewed reported the existence of VHTs in their villages with
exceptions of urban areas such as Soroti & Mbarara municipalities and Kampala city.
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“We do not know the work of VHTs we just see them at the facility and if we want
medicine they give us medicine and we go. But we basically do not know what they do
there and what they are supposed to do”. FGD_Community, Kampala district
The communities commonly referred to VHTs as village doctors, community health workers and
health promoters arising from the roles and services performed by VHTs such as treating
children under five years, immunization, distribution of drugs and promotion of hygiene and
sanitation.
“Those community health workers are good. They mobilize us to maintain hygiene,
construct toilets, drying lines and rubbish pits and also distribute nets”.
FGD_Community, Butaleja district
Generally, the community perceived VHTs as committed and passionate about their work. In a
number of instances, community members reported having provided VHTs with food, transport
and free water from bore holes in appreciation of VHT work to the community.
“They are really so committed and helpful because you find them and tell them of the
disease affecting your child and they take it as an initiative to come to your home to
extend treatment to the child. They really work because they have record books and here
at the health center you find our names in those record books and this justifies how they
work hard”. FGD_Community, Kyankwanzi district
“Before we can inform the VHTs trust me they will have known. These people are very
good at their work”. FGD_Community, Hoima district
“VHTs are allowed to get water freely from the community bore holes in appreciation of
their good work”. FGD_Community, Moroto district
To a large extent, the services provided by VHTs were considered commensurate to the needs
of community members. Community members reported improvement in hygiene and
sanitation, uptake of immunization, antenatal care and HIV services and reduction of illnesses
and deaths in the community as direct efforts made by VHTs
“I used to suffer a lot from typhoid because I never had to boil my water but now I boil
my water and I do not fall sick anymore. Even my children do not fall sick of malaria
anymore”. FGD_Community Mbale district
“What VHTs have done initially, initially children used to suffer from measles and one
thought it was witchcraft, however when these people came, they encouraged parents
to take their kids for immunization, they have advised pregnant women to go for
antenatal services”. FGD_Community Gomba district
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“Even those VHTS the big job I see them doing in the community is that people in the
community used to fear to go for HIV Tests because they would stay in the village and
fear to disclose their sickness but when the VHTS find out about them they go down to
them in the village, counsel them and create for them conducive grounds of which finally
the people who have HIV come to the health centre to carry out tests. But now ever since
that happened you find that people have gained courage and confidence and come to
the health centre to get tested because of the counseling they got from VHTS. You see
they are now better people compared to how they were before they came for testing”.
FGD_Community Luwero, district
Although community members largely considered VHT roles as meeting community needs,
there were instances where the services provided did not meet community expectations as
cited in the extracts below;
“They used to perform their duties but now these days we don’t know if there was
change in leadership at the top most because for sure drugs are no longer available at
all. And if you go with a child you find they have no medicine and you bring the child to
the health center”. FGD_Community, Kyankwanzi district
“Some people tell VHTs that “you who did not go to school, how do you teach me about
latrine construction, you come here for my wife”. FGD_Community, Kamuli district
“In town many people are wiseacres they do not mind about people who come to talk to
them about health, they just wait till when their children are sick and they go to hospital
so they do not give any attention to VHTs”. FGD_Community, Kampala district
Lack of drugs and low levels of education of some VHTs have contributed to negative
perceptions of community members towards VHTs in communities. In addition, VHTs are
largely existent and known in rural settings compared to urban settings.
Discussion
The majority of the rural community members interviewed reported the existence of VHTs in
their communities. To a large extent, the services provided by VHTs were considered relevant
to the health needs of community members. Community members reported improvement in
hygiene and sanitation, uptake of immunization, antenatal care and HIV services and reduction
of some illnesses and deaths in the community as direct efforts made by VHTs.
This therefore implies that the VHT programme is perceived to be functional by the rural
communities. However in the urban setting, the communities did not know much about the
programme since the VHTs do not visit their homes. This brings into question the functionality
of the programme in the urban communities.
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4.7.4 Functionality of Iindividual VHT Members
The individual VHT member functionality was assessed based on the following criteria: access
to equipment and supplies, VHT referral and follow up, supervision and reporting.
Table 21: Functionality of VHT members
Indicator of functionality n Percent
VHT referral and follow up
Conduct referral and follow up 1779 68
No referral or follow-up 831 32
VHTs being Supervised
Yes 1787 70
No 781 30
VHT submitting Reports
Yes 2370 91.2
No 228 8.8
VHT Participation in coordination meetings
Yes 2038 79
No 545 21
Table 21 indicates that majority of VHTs referred clients to health centres (68%), were supervised (70%) and were reporting (91%). The reporting tools were majorly provided by IPs. Less than 50% of the VHTs reported having all the equipment. However, there was no evidence of support supervision reports to the district. The VHTs also reported multiple reporting formats from partners which became a burden to VHTs especially those with low or no education.
Discussion
Although most of the VHTs reported to have been supervised, there was no evidence of support
supervision reports to the districts. VHTs reported being supervised by health workers at health
center IIs. However, these health workers lack facilitation in terms of transport and may not be
adequately trained for this purpose. The quality of supervision may therefore be low. The VHT
members also have multiple reporting formats from partners which became a burden to VHTs
especially those with low or no education.
4.7.5 VHT drop outs (Attrition)
For a VHT to be considered as a drop out, he/she no longer carries out any role related to the
VHT programme in the community where he or she was trained. The assessment found that of
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the 56 district VHT Focal Persons who provided information on VHT drop outs, there was about
30% VHTs dropped out (Table 22). As noted, this is a reported figure and we did not have the
necessary documentation to verify this. The Northern region had the highest attrition due to
camp decongestion and resettlement of former Internally Displaced Persons (IDPs) which led to
relocation and eventual drop out of some VHTs. Other causes of the drop out were: change of
residence, death, employment, low motivation and marriage.
“In other cases, VHTs were trained but they drop out. Others shift to other areas such as
Kampala and others die yet they haven’t been replaced. We also need more VHTs. The
ones we have are not enough. The district does not have funds specifically allocated to
the VHT programme and therefore facilitation of VHTs is not easy”, KII_Rukungiri
district.
“The high attrition rate is due to volunteerism. The VHTs are not seeing this programme
as motivating. Some VHTs prefer doing something where they get some money and so
others have gone to South Sudan”, FGD_VHT, Moyo district.
Table 22: Number of districts that reported VHT dropout rate region
Region Frequency Mean dropout Percentage
Northern 14 38
Karamoja 02 03
Eastern 16 27
Central 14 28
Western 10 26
Total / Mean 56 30
A 30% drop out rate is high and affects the functionality of the VHT programme in as far as the
number of people to conduct community health activities and the costs of recruiting and
training other replacements and performance of VHTs are concerned.
4.7.6 Sustainability of the VHT programme
The VHT programme has had a quite significant effect on the improvement of the delivery of
primary health care services to the communities in Uganda. Such activities include hygiene and
sanitation improvement, immunization, indoor residual spraying, HIV/AIDS, TB and malaria,
family planning, maternal and child health and NTD services. These services have been
appreciated by the some community members, the district leaders and the healthcare workers.
Moreover, the community members participate in the selection of VHT members, thereby
creating a sense of ownership in the process hence providing a ground for sustainability.
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However, several challenges with sustainability of the VHT programme were reported as
illustrated in the excerpts below;
“MOH does not have clear harmonized position for financial sustainability of the VHT
program”, KII_MoH.
“Government should encourage partner to use VHT but the VHT should be controlled
by the Government”, KII_MoH.
“Funding is the root cause of all the challenges VHTs are facing because without
funds activities like supervision capacity building and motivation would be hard or
near impossible to implement”, KII_Mbarara
In its current form, the programme is not sustainable as it is highly dependent on IPs. There is
need to ensure that the VHT programme is not dependent on volunteerism and financing
mechanisms are put in place, harmonized and sustained.
“Partners can come together and have a VHT fund. This VHT fund can be put in a basket
and then we know that from this district for the VHTs, there is this fund and the districts
can break it down to ensure that the whole district is covered, the tools are harmonized
and all the VHTs are remunerated depending on how much money is available”,
FGD_DHT, Kamuli district.
Discussion
Dropout rates
The high dropout in the North (38%) may be due to the fact that the camp situation brought
many villages together and the trainings provided to VHTs then may have only benefitted VHTs
from some villages and not others. The VHT training started about 15 years ago in northern
Uganda compared to other regions. The VHTs may have naturally dropout due to other
employment, death and retirement. The high expectation on benefits from the programme may
have caused high attrition when the expectations were not fulfilled.
Low drop out in Karamoja region was reported by two districts. VHTs in Karamoja were trained
in the last five years and may be a reason why there is low drop out as compared to the
Northern region where VHTs were trained over ten years ago.
Secondly, there is more support being provided to VHTs in Karamoja region under ICCM
programme by UNICEF. However, this study did not correlate the low drop out in Karamoja
region and service delivery or health indices.
Sustainability
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The VHT programme seems unsustainable due to heavy dependency of partners. The MoH does
not have a clear harmonized position for financial sustainability of the VHT program.
4.0 Discussion
Number and Socio demographics
The assessment revealed that there are a total of 179, 175 village health team members in the
112 districts with only 119,026 who have had the basic training. These are estimates as
reported by the District VHT Focal Persons. With 57, 735 villages in Uganda, this translates into
3 VHTs serving a village.
This figure, however, may be inaccurate since there are some districts such as Kibuku, Kampala,
among others that have not carried out the basic VHT training. The number of VHTs are as
reported by the districts and could not be independently verified. The regional imbalance in
VHT distribution in VHT coverage requires government to conduct VHT training in districts that
have not yet had their own trainings to ensure equitable delivery of health services.
The assessment found that just over a half (52%) of VHTs were below 40 years of age. They are
able to sensitize the communities on health promotion but also do other health related
activities. This age bracket may be more susceptible to attrition as they are considered more
energetic and mobile. Some of the VHTs were fifty years or older, a factor that may have led to
inefficiencies with regards to report writing and swift movement during mobilization activities.
For example, administrators in districts such as Kalungu, Butambala and Mpigi expressed
dissatisfaction with the manner in which the older VHTs were performing in terms of reporting
and drug distribution as well as efficiency in movement during mobilization.
“Some of the VHTs in this area are aged and cannot see well”, FGD_DHT, Butambala district.
Given the unique challenges of the young ones less than 40 and the old one ones more than 40
years of age, there is need to review the guideline for eligibility and recruitment of people to be
trained as VHTs.
While the majority of the VHTs interviewed (54%) were male, the assessment could not
establish the sex composition of the VHTs in the Country due to the absence of VHT databases
in the districts.
The data shows that more than 50% of the VHTs have attained at least 0-Level education and
can therefore read and write. This position was also supported by community data showing
preference for people who have attained 0-Level education and above. This would imply that
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Government could consider the minimum level of education for a VHT could be 0-Level. This
would suit the expanding scope of responsibilities of VHTs such as administering antimalarial
drugs, data gathering and reporting, family planning.
However, it should also be pointed out that there is a challenge of identifying people with 0-
Level education in some places, more especially in Karamoja region, where about 20% of the
VHTs had at least O Level education as compared to the rest of the Country.
VHTs are involved in various activities. The majority of the VHTs (86.2% males) and 85.6%
females were engaged in farming. However, the findings indicate that some VHTs are employed
by NGOs; some are students while others are LCs. These categories of VHTs may not have
sufficient time to do VHT work and it is inconsistent with the VHT selection guidelines. Some of
these individuals could have joined VHT work due to high expectations as noted in the
interviews. It is therefore observed that the VHT selection guidelines have not been adhered to.
Training of VHTS
The study found that there are no training databases for the VHTs in the districts and at the
national level. Some of the VHT Focal Persons in the districts are new and because they lack
VHT databases in the district, they therefore may lack information on what has happened in the
programme in the previous years. This result may also mean that the number of VHTs may not
be accurately known at the national level.
Despite the high number of VHTs in the Eastern region, the majority have not had basic VHT
training. The high number of untrained VHTs in Eastern region shows disfunctionality of the
VHT programme. People who did not receive basic training were considered VHT members in
some districts. For example, in Kampala district where no basic training has taken place, 351
people were reported to be VHTs. These were only trained on programme-specific areas. In
such districts, it is apparent that the VHT guidelines have not been followed with respect to
training.
It was noted that the content of the basic training reported by VHTs was largely consistent with
the content stipulated in the VHT operational guidelines. However, this content may not have
been fully covered in the short duration of the training (5-7 days) even when qualified trainers
were used. The reduction of the training duration by the Ministry of Health from 10 to 5 days
may have led to rushing of the trainings. The trainings may have been inadequate to equip the
VHTs with appropriate knowledge and skills. This therefore could affect the quality of services
VHTs provide to the community.
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At times, trainings are conducted directly by the IPs without notifying and involving the DHTs or
using the district trainers. This indicates a problem of VHT programme coordination,
streamlining and training.
Since IPs choose where to go and implement their programmes, it creates disparity in the
capacity of VHTs since trainings are provided to some VHTs in some areas and not to others.
This leads to differences in knowledge and skills levels among the VHTs. Such a situation may
lead to demotivation of the VHTs who have missed the training and may result into drop out.
Poor IP coordination creates a problem in supervision of the programme and eventually in
sustainability when the partners’ projects end. In areas with few or no implementing partners,
it implies that the communities may not be benefitting from the VHT activities supported by
such partners.
While these multiple trainings can strengthen the capacity of VHTs to deliver services to the
community and provide feedback to the health facility staff, it also means that the same VHTs
receive multiple trainings which increase their reporting burden. It may also mean there is
inadequate time to have quality training given the low level of education of some of the VHTs.
Partners supporting VHT programme and activities the VHTs are implementing
Implementing partners have made significant contributions to the overall implementation of the
VHT programme through the provision of financial, technical and logistical support. This support
has improved utilization of health care services provided by VHTs in the areas of immuniuzation,
sanitation, HIV/AIDS services, antinetal care, deliveries and family planning services.
However, there is inequitable distribution of partners among and within districts. This may be
caused by the uncoordinated selection criteria of the districts of operation. This leads to
inequitable distribution of skills among VHTs. Districts with many partners may have VHTs who
are more skilled than those with few partners or none at all. This has implications on quality of
health care services VHTs deliver to the community.
The roles played by the VHTs as indicated by the Community FGD data are reflective of the
content of the VHT training. The most common roles played by VHTs are community
mobilization and this is consistent with the content and requirement of the basic VHT training
guidelines.
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The community members are appreciative of the roles played by VHTs in health service delivery
especially in hygiene and sanitation, drug distribution, antenatal care, HIV and family planning.
Although the VHT programme is owned by the Government of Uganda, the assessment
established that VHTs pay more allegiance to the IPs who provided them with more facilitation
than government. This is reflected in the VHTs willingness to participate in IP related projects as
opposed to those for the government where there is less or no facilitation.
Extent to which Implementing guidelines are being followed
Selection
The VHT selection guidelines are in place and have largely been used. This is evident in the
involvement and participation of the communities in selecting VHTs. However, a small
proportion of VHTs were selected not in accordance with the guidelines in place. This included
selection by local leaders, self-selection and selection by IPs. This may imply that the quality of
VHTs not selected according to the selection guidelines may not meet the selection criteria such
as being able to read and write or trusted, committed to working and are permanent residents
in the community.
Training
Whereas the guidelines and training manuals to support VHT trainings are in place, nearly a
third of VHTs have not received basic training. This may have been as a result of a number of
factors such as; lack of funds by districts to conduct basic trainings, self appointment and
selection by local leaders and by IPs. Such tendencies to select VHTs without the community
involvement could have been due to lack of supervision by the districts. Consequently, a
substancial number of VHTs may lack adequate skills to perform their duties.
The one third VHTs who received basic training in only 1-4 days imply that the training duration
guidline was flouted. This may have therefore lowered the quality of the training conducted as
the training period is too short to equip the VHTs with the necessary knowledge and skills.
Though the training period of 5 days of basic training is in the guidelines, it is however too short
for the trainees to comprehend all the content and apply it. Besides, the varrying education
levels of VHTs affect their ability to comprehend the content of the training.
Programme-specific trainings by IPs are not harmonized in terms of standadized materials,
content, duration and methods. This clearly is not in line with the guidelines on refresher
training.
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Supervision
The assessment revealed that VHTs are supervised at the health center IIs or IIIs or IVs and at
district level as stipulated in the guidelines. However, there were no supervision check lists and
reports ascertained. Supervision of the VHTs was hampered by lack of resources including
funds, transport and technical capacity for supervision.
Supervision was undertaken mainly by Health Assistants, In-charges of health centers and
Parish VHT supervisors and LC I Chairpersons as well as by NGOs and CDOs. The selection of
VHT Supervisors was not rigorously followed except in only 5% of cases. It was however
difficult to ascertain whether these various supervisors and the VHT members themselves
understood what supervision entails.
Therefore, the lack of supervision tools, reports and apparent understanding of what
supervision entails leaves gaps in determining whether the supervision reported to have been
carried out was effective. The lack of reports suggests that supervision may not have taken
place. The non-adherence to the VHT Supervisors’ selection guidelines therefore compromises
the quality of VHT supervision.
Reporting
The assessment showed a hierarchical reporting from the village through the parish (health
centre), sub-county to the district levels. However, in some districts such as Otuke, Sheema and
Buhweju, there was practically no reporting due to various reasons including the lack of tools
and lack of training. The study however did not determine whether the hierarchical reporting
existed in every district. The absence of reporting tools and training on reporting constrained
reporting and suggests the need for capacity development in this area.
Various reporting formats and tools were used including mTrac. However, paper-based forms for
reporting were found to be the most commonly used in most districts. Reporting tools were
mostly found with implementing partners. This implies that reporting took place based on
availability of tools in settings and programmatic priorities of implementing partners. It may also
imply that VHT supervisors at health center levels could only exercise limited supervision on
VHT reporting. The inadequate reporting tools, existence of various implementing partners and
reporting formats coupled with low education level of some VHTs therefore suggest that there
was irregularity and poor quality in reporting.
Coordination
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There are VHT operational guidelines in place to support coordination mechanisms. However,
poor coordination has arisen due to human resource and financial constraints mainly at
national and district levels. The irregularity of the quarterly national steering committee
meetings could have led to increasing gap in VHT coordination with and within districts. Lack of
coordination led to poor supervision of IPs and their activities.
Referrals
The assessment established that most of the VHTs referred clients to health facilities. However,
the assessment also found out that Health workers sometimes did not respect referrals made
by VHTs. This emanated from the fact that VHTs are considered people of low education who
are not competent in disease management as they are not medical personnel.
It was not clear whether referrals made by VHTs were effetively handled by the service
providers at the health facilities. In addition, the assessment found that there were other
concerns that affected effective referral such as lack of medicines in and transport means to
health centers.
Approaches for Motivation
The provision of monetary and non-monetary incentives to VHTs contributes to motivation and
retention of VHTs. While the VHT Operational Guidelines stipulate the various forms of
motivation for VHTs, it does not explicitly describe how these should be equitably distributed
and who should provide these incentives. For instance, the financial forms of motivation did not
have the educational level required and yet government does not pay workers without formal
education. The minimum package did not stipulate a salary but a reimbursement of costs for
transport or for meals. In addition the MOH guidelines did not provide clarity on what
constitutes activity and performance-related incentives.
While there are economic and social benefits of volunteerism, maintaining the VHTs to perform
their functions can be eroded over time if some basic needs are not met. Some VHT who
volunteered had high monetary expectations and if these were not met, some dropped out of
the VHT program. Some of the materials provided were just tools but were not meant for
motivation. Although those materials were meant as materials to facilitate VHT activities, they
provided motivation to VHTs. The study found that there are certain things beyond what was
thought as motivation to VHTs. Qualitative data showed that there is an overwhelming demand
for a harmonised and regular financial form of motivation for the VHTs.
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The various ways of motivation are not uniform thus creating disharmony at the district level
and among the VHTs hence making coordination ineffective. Although the MoH, Partners and
IPs are providing different kinds of motivation, there is no system for tracking the different
motivation packages and support for VHTs hence there is need for harminizing motivation
approaches and packages to address these anomalies.
Functionality of VHT programme and VHTs
National level
Lack of funding is a major challenge to the VHT activities at national level. As a result,
coordination, and supervision of VHT activities have not been adequately done. Training of
VHTs has not been completed in all the districts as a result of lack of funding. Lack of personnel
in the coordination office has created a huge gap where the national coordinator is expected to
do all the coordination work.
The MoH does however have other opportunities for supervision such as the Area Team
supervision where VHT activities have been supervised but this is also irregular due to
inadequacy of funding.
Overall, at national level, the VHT national coordination office is poorly facilitated to enable it
efficiently implement the strategy as stipulated in the guidelines.
District level
Although the majority of the districts followed the guidelines in recruitment, carried out ToTs,
have VHT trainers and conduct refresher training, the VHT programme is none functional on
district funding to the programme, coordination and supervision. This is mainly due to lack of
funds to finance these activities in the districts.
Community level
The majority of the rural community members interviewed reported the existence of VHTs in
their communities. To a large extent, the services provided by VHTs were considered relevant
to the health needs of community members. Community members reported improvement in
hygiene and sanitation, uptake of immunization, antenatal care and HIV services and reduction
of some illnesses and deaths in the community as direct efforts made by VHTs
This therefore implies that the VHT programme is perceived to be functional by the rural
communities. However in the urban setting, the communities did not know much about the
83
programme since the VHTs do not visit their homes. This brings into question the functionality
of the programme in the urban communities.
Individual VHT functionality
Although most of the VHTs reported to have been supervised, there was no evidence of support
supervision reports to the districts. VHTs reported being supervised by health workers at health
center IIs. However, these health workers lack facilitation in terms of transport and may not be
adequately trained for this purpose. The quality of supervision may therefore be low. The VHT
members also have multiple reporting formats from partners which became a burden to VHTs
especially those with low or no education.
5.0 Recommendations
Numbers and Socio demographics
1. MOH should include stipulation in the selection criteria to Increase the number of VHTs
under the age of 35 to more effectively reach young people in the community. Selection
criteria should be revised in a way that takes into consideration communities’ cultural
values while also encouraging a greater number of younger VHTs within the overall
selection.
2. The minimum education level for VHTs should be specified at ‘O’ level. However
consideration should be made for the differences in education levels between the
regions. In urban centres, there need to recruit VHTs of higher levels of education to
match the population that lives in these areas.
3. Engage more female VHTs in recruitment to handle specific female health needs such as
reproductive health issues that women feel uncomfortable to share with male VHTs.
Training and Supervision of VHTs
1. Given the increasing expectations of the roles of VHTs, the duration, content,
methodology of VHT training should be reviewed and revised with the intention of
making it commensurate with the skills to be developed. In addition, inclusion of
content around gender and values clarification around serving young people (e.g.,
addressing myths and misconceptions on family planning use by young people and
nulliparous couples) is needed to address VHTs’ attitudes and ability to effectively
deliver services.
84
2. The VHT programs should be coherently inserted in the wider health system, and
should be explicitly included within the human resources for health (HRH) strategic
planning at country and local level.
3. MOH should put in place clear, measurable mechanisms of VHTs role in primary
health care, to ensure that a core set of skills and information related to MDGs be
provided to VHTs. The proposed revised VHT curriculum should incorporate
scientific knowledge about preventive and basic medical care, and how they relate
these ideas to local social issues and cultural traditions. They should be trained, as
required, on the promotive, preventive, curative and rehabilitative aspects of care
related to maternal, newborn and child health, malaria, tuberculosis, HIV/AIDs as
well as other communicable and non-communicable diseases.
4. There is need to establish a VHT database at the district level to track all district level
VHT trainings and other activities. However, this needs control and coordination of
all district level VHT trainings and other activities by MOH and the District Local
Governments.
5. The MOH should ensure that all VHTs in the districts should undergo VHT basic
training, especially in Kampala and the newly created districts.
6. There should be coordination of refresher training by the MOH and the District
Health Teams and IPs to ensure uniformity of the VHT training with regard to
standardized materials, content, duration and methods based on VHT roles and
functions and fair coverage and should be more inclusive of the content of the basic
training since the current training is more programme-driven. The refresher training
should only target VHT who have completed the basic training.
7. Considering the ever changing roles of VHTs it is recommended their roles and
responsibilities be reviewed and updated thus stipulating suitable duration of days
for training. There is need to identify other innovative ways of training to ensure
content is covered and skills are.
8. MOH and districts in close collaboration with IPs should ensure reliable provision of
transport, drug supplies and equipment for VHT effectiveness in implementing their
activities. Supplies’ of drugs and related commodities should be brought to the
Health Center IIs for the VHTs to easily access them.
9. MOH and Districts should revise the training curriculum for supervisors and ensure that VHT supervision checklists exist and are put to use by VHT supervisors. MOH and DHTs should revise supervision tools, report formats/tools for VHTs and checklists for understanding of what supervision entails to ensure effective supervision of VHTs as well as harmony with IPs expectations. MOH and districts should enforce adherence to the set criteria for selection of VHT supervisors and build their capacity to perform that role. MOH should ensure that VHT supervision checklists are developed and disseminated to the districts. The districts should
85
ensure that VHT supervision checklists are put to use by the VHT superviors. Reports of VHT supervision should be written and submitted by supervisors to appropriate offices as stipulated in the VHT operational guidelines. MOH and districts should revise the training and support supervision activities to ensure positive attitudes of health workers towards VHTs.
10. MOH and districts should ensure that VHTs have appropriate tools for regular reporting feeding into respective district HMIS. MOH and districts should ensure that VHTs have the right skills and tools to undertake effective data collection, report writing and timely report submission.
11. Indicators that specifically track VHT interventions e.g VHT trainings should be developed in the HMIS so as to track effectiveness and performance of VHT member’s work. The VHTs should be oriented on the importance of tracking, collecting and reporting of these indicators using the revised VHT reporting formats during the VHT trainings.
Partners supporting VHT programme
1. MOH and the district leadership should play a role to ensure a more equitable
distribution of implementing partners among and within districts. In addition, MOH
should regulate partners working within the same district but working in the same
programme area.
2. MOH should use district based VHT and IPs mapping to coordinate and harmonize
the VHT activities in the districts. This will improve the inequity of VHT coverage and
service delivery. It will also strengthen government leadership and ownership of the
programme.
Implementation of the guidelines
1. The DHT and district leaders should ensure through supervision a clear selection and
deployment procedure for VHTs and their Supervisors. Ideally they should engage
community in planning, selecting, implementing, and monitoring that reassures
appointing those who certify the course completion and pass the writing or verbal
exam at the end of training. MOH and local leadership should take responsibility in
making a transparent system for selection and deployment and further quality
assurance of the regulated set system.
2. MOH and districts should streamline reporting structure to ensure compliance to
the VHT operational guidelines on reporting
3. Government should provide adequate funding for the Ministry of Health to have an
efficient national steering committee and for coordination of VHT activities
nationally and at district level as well as at the community level.
86
4. There is need to sensitize health workers in the health centres and the communities
at large about the mandate of the VHTs. This will create harmony and good working
relationship between the VHTs and the health workers.
5. MOH should advocate/lobby Parliament to provide adequate funding and annual
budgets for VHT activities nationally, at district level as well as community.
6. MOH in the revision of training and support supervision guidelines should develop
an effective tracking system to ensure that patient referrals are effective and can be
evaluated.
7. MOH should develop and use effective checklists on attitudes of health workers and
communities towards VHTs‘work.
Motivation mechanisms
1. There is need to provide a standardized and harmonized regular and equitable financial
form of motivation to VHT and to ensure equitable distribution of non-monetary
incentives to all VHTs.
2. MOH should lobby Parliament to establish Performance Based Financing system (PBF
model) in which a base salary is paid for core activities, and an additional bonus can be
earned for excellent performance for additional activities.
3. Non- monetary recognition of VHTs as a formal cadre of health worker, integrated into
the public health system, with all that that entails (payment, rights, supervision and
assessment).
4. Government should review the number and level of education of VHTs if a standardized
remuneration systems is introduced such as wages or salaries.
5. MOH should develop career path development plans for VHTs as a motivational
function.
6. Government should take lead in clarification and provision of the motivations and
incentives mentioned in the VHT operational guideline.
7. Revise HMIS to include household data on basic public health indicators collected by
VHT system.
8. Establish use of mhealth tools such as the routine messaging tool for household health
data collection that feeds into district HMIS, and for monitoring VHT performance.
9. For motivation to be effective there is need to have a database of VHTs with their full
names and photographs. This helps in tracking the existence of the VHTs and the
Authenticity of these VHTs if they have to be introduced to a remuneration payment
system.
10. Government and IPs need to undertake proper planning on the proposed financial
mechanisms of VHT motivation prior to adopting such suggestions. Government and IPs
should take a cost-benefit analysis of these suggested motivation mechanisms to come
87
up with the most suitable mechanisms that are within government means to motivate
the VHT members
Functionality
1. A VHT Policy should be formulated which should guide the Strategy development
which should be costed and funded.
2. MOH should advocate/lobby Parliament to provide adequate funding for VHT
activities nationally and at district level as well as at the community level.
3. MOH and the district health offices should coordinate the IPs in terms of activities
implemented and geographical coverage in order to reduce the concentration of IPs
in some areas.
4. There is need to empower the VHT department at the MOH with adequate funding
and increase personnel to enable them to efficiently implement the strategy
5. A national basket fund should be established to which donors contribute and which
can be used to pay VHT salaries and any other additional costs such as training,
supervision, supplies etc. that will be covered.
6. MOH should routinely monitor district based databases for VHTs and their activities
to ensure coordination of all IPs targeting VHTs. This will help in equity geographical
distribution of service delivery as well as skills and knowledge among VHTs.
7. The districts should include in their annual workplans and budgets VHT activities and
MOH should ensure timely disbursement of funds.
8. MOH should develop an urban- specific strategy that prioritize by parish or villages
with the worst public health indicators such as slum areas, and the lowest service
provider to population ratios. The most underserved parts of the cities/towns should
be addressed first with later expansion to the rest of the city as budget permits.
88
6. 0 Appendices
Appendix 6.1 Number of VHTs in the districts
District Number of VHTs
ABIM 718
Adjumani 826
AGAGO 1969
Alebtong 1210
Amolatar 870
AMURU 720
Apac 3500
Arua 200
Dokolo 958
Gulu 1561
Kitgum 1534
Kole 1114
Lamwo 1198
Lira 210
Maracha 1184
Moyo 1642
Nebbi 879
Nwoya 874
Otuke 790
Oyam 4976
Pader 1300
Yumbe 1272
Zombo 1669
Koboko 120
AMUDAT 244
Kaabong 920
KOTIDO 365
Moroto 365
Nakapiripirit 343
Napak 60
Amuria 3630
Budaka 798
Bududa 1902
89
Bugiri 2285
Bukedea 682
Bukwo 1054
Bulambuli 2820
Busia 1710
Butaleja 1000
Buyende 1615
Iganga 715
Jinja 1930
Kaberamaido 82
Kaliro 1465
Kamuli 3456
Kapchorwa 1484
Katakwir 1540
Kibuku 492
Kumi 871
Kween 968
Luuka 1275
Manafa 3031
Mayuge 2500
Mbale 3214
Namayingo 1250
Namutumba 1815
Ngora 665
Palisa 1712
Serere 1480
Sironko 2570
Soroti 1398
TORORO 4375
Buikwe 1870
bukomansimbi 1016
BUTAMBALA 640
Buvuma 300
GOMBA 1018
kalangala 480
kalungu 1140
Kayunga 1875
90
Kiboga 1143
kyakwanzi 62
Luwero 2980
lwengo 1802
lyantonde 150
masaka 1400
MITYANA 150
MPIGI 1354
MUBENDE 309
Mukono 2547
Nakaseke 656
Nakasongola 1405
rakai 4500
sembabule 1500
WAKISO 2880
Buhweju 1235
BULIISA 418
Bundibunjo 2548
Bushenyi 1713
Hoima 1124
ibanda 1750
Isingiro 3325
kabale 4437
Kabarole 3000
Kamwenge 2560
Kanungu 1760
Kasese 1023
Kibaale 7620
kiruhura 3408
KIRYANDONGO 412
Kisoro 2200
Kyegegwa 1430
Kyenjojo 5246
MASINDI 1328
Mbarara 2582
Mitooma 1198
Ntoroko 1312
91
Ntungamo 3695
Rubirizi 1020
Rukunguri 1119
Sheema 1160
Appendix 6.2 National Partners for interview
PARTNER KEY INFORMANT COMMENTS
PACE Amon Done
World Vision Geofrey Babugirana Done
UNFPA Roseline Achola Done
Pathfinder International
Uganda
Karamagi Charles Done
Marie Stopes Uganda Dr. Herbert Muhumuza Done
AMREF Dr. Kagurusi Done
UNICEF Charles Loada Done
Malaria consortium Denis Mubiru Done
Reproductive Health Uganda Kansiime Doreen Done
Uganda Health Marketing
Group
Eva Kaggwa Done
FHI 360 Done
POPSEC Done
Appendix 6.3 List of partners working with VHTs in districts
DISTRICT PARTNER AREA OF OPERATION
KARAMOJA REGION
Moroto UNICEF Nutrition
UNFPA Malaria
International Rescue
Committee
PMTCT
CAUMM ICCM
Nakapiripirit
UNICEF Nutrition
International Rescue
Committee
HIV
CAUMM ICCM
WAP
92
CONCERN
Amudat
International Rescue
Committee
PMTCT
Vision Care ICCM
FOREF HIV
UNICEF Nutrition
Pilgrim Uganda Malaria, HIV, diarrhea
Marie Stopes Maternal health
CAUMM ICCM
Napak
UNICEF Nutrition
International Rescue
Committee
PMTCT
CAUMM ICCM
Sight Savers
Samaritan purse Sanitation and hygiene
Katakwi
Baylor Uganda HIV, Malaria
UNFPA Malaria
LWF
TASO HIV/AIDS
Kaabong
World vision Nutrition
UNICEF Nutrition
International Rescue
Committee
PMTCT
Community action for health Nutrition
Abim
UNICEF Nutrition, support review
meetings
World vision Nutrition
Community action for health Nutrition
Baylor Uganda HIV reporting
GOAL
Kotido Community Action For Health Nutrition
93
World vision HIV
International Rescue
Committee
PMTCT
UNICEF Nutrition
Amuria
World vision Nutrition
TASO HIV/AIDS
Baylor Uganda HIV/AIDS
Pilgrim Malaria, HIV, diarrhea
Uganda cares HIV
Eastern
Soroti World vision Malaria
AMREF TB
AIC Malaria
Uganda Cares HIV
Baylor Uganda HIV/AIDS
Mental Health Project
Serere
Baylor Uganda HIV/AIDS
AMREF Reproductive Health
Partners For Children World
Wide
Livelihood And Sanitation And
Reproductive Health
Staying Alive Fistula and supporting
households with equipments
Health Need Reproductive sanitation
HOW Uganda Reproductive Health
Hope for OVC Uganda
Pentecostal Assembly of God
Pilgrim Management of malaria
SORUDA Uganda Reproductive health and
sanitation
Ngora
Baylor Uganda HIV/AIDS
Pilgrim Malaria, HIV, diarrhea
THETA PMTCT
PACE Malaria
Uganda sanitation fund Hygiene and Sanitation
94
Bukwo
PACE HIV,TB,PMTCT
CARITAS HIV and AIDS,TB
Star Ec HIV/AIDS,TB
Strengthening
Decentralization Systems(SDS)
Health system strengthening
Kween
PACE HIV/AIDS, Malaria, TB
Star E HIV/AIDS,TB
Kapchorwa
PACE Malaria
Star E HIV, TB
Bukedea
Pilgrim Management of malaria
Baylor Uganda Referral, community linkage,
HIV/AIDS, sanitation
Maritza international
Bulambuli
PACE Malaria control and
prevention
Salvation army Reproductive health
Manafwa
TASO HIV/AIDS, Referrals, maternal
health
PACE Family planning, malaria and
nutrition
Salvation Army Family planning
Mbale Cap Maternal health
Kumi
Baylor Uganda HIV/AIDS, maternal health
Pilgrim Reproductive health and
family planning
PACE malaria and nutrition
Strides Maternal, Newborn and Child
Health
Star E HIV/AIDS
Friends of Kumi
95
Private Sector Training
Sironko
PACE Malaria, HIV/AIDS and
Reproductive health
Buyobo Development
Association
Micro finance and soft loans
Salvation army Family planning
Star E HIV/AIDS,TB
Mbale
PACE HIV/AIDS
World vision Girl child and Child upbringing
Malaria consortium Malaria prevention and
control
SPOT LIGHT ON AFRICA Water source treatment, H/C
construction
Bududa
PACE Malaria, HIV/AIDS and TB
UMODA HIV/AIDS
SCORE Family planning
DATA Maternal health
PATH Family planning
PONT Uganda Capacity building
Tororo
Plan Uganda ICCM
World vision Nutrition
East Central
Mayuge Star EC TB/HIV
Strides Maternal, Newborn and Child
Health
Family life education program family planning
Makerere SPH New born care
Paliisa
MANIFEST Maternal and Newborn
Health
Star ec TB, HIV
Kagum development
organization
Maternal health
96
Kibuku
Uganda Sanitation Fund Hygiene and Sanitation
MANIFEST Maternal and Neonatal Health
Kagum development
organization
Maternal Health
Kadama widows association HIV/AIDS
Star EC TB, HIV
TASO HIV/AIDS
Budaka
KADO Maternal Health
Salvation Army Reproductive Health
Child fund Maternal, Newborn and Child
Health
Star e HIV/AIDS
Strengthening
Decentralization Systems(SDS)
Health system strengthening
Butaleja
World vision Maternal, Newborn and Child
Health
Child fund Child Health
Salvation Army Reproductive health
Namutumba
Star ec HIV/AIDS and TB
Marie Stopes Family planning
Spring Nutrition
Kagum Development
Organization
Malaria, TB, HIV
Envision
Accelerating Nutrition
Intervention(ANI)
Nutrition
Busia
World vision Maternal, neonatal and child
health
PACE Malaria
Salvation army Family planning
Child fund Livelihood and child health
Star ec TB
97
Family health
international(FHI)
Family planning
Namayingo
Star ec HIV/TB
PACE Malaria
GOAL WASH
Mother To Mothers HIV in pregnancies and
lactating mothers
Bugiri
Star EC HIV, TB
World vision MNCH
Strides MNCH
PACE Malaria
Link up project
ACCORD
Luuka
Star EC HIV and TB
Kagum development
organization
Long lasting nets, pregnant
mothers and children
PACE Malaria
Buyende
Star EC TB, HIV and Malaria
MANIFEST Maternal and child health
Community vision Livelihood
Kagum Development
Organization
HIV, TB Malaria
Kamuli
Plan Uganda ICCM
MANIFEST MNCH
Star EC TB, HIV, Malaria
Strides MNCH
Kaliro
Strengthening
Decentralization Systems(SDS)
Health System strengthening
Star EC TB, HIV
PACE Malaria
Strides MNCH
98
Kagum Development
Organization
HIV, TB, Malaria
Central 2
Nakasongola AMREF Malaria
Save the children Reproductive health
PREFA Prevention of transmission
from mother to child
World vision Nutrition and sanitation
Strides MNCH
Save foundation
UNICEF Family health days
Nakaseke
Busoga Trust HIV and malaria
Mild may HIV
Kiboga
Malaria consortium Drug distribution
World Vision Nutrition and sanitation
Kyakwanzi
Malaria consortium ICCMs
World vision Nutrition and Sanitation
AMREF Malaria
Luwero
PLAN ICCM
UNHCO
CORDI
Busoga trust HIV and malaria
AMREF Malaria
PACE Malaria
Caritas
Health Wine
Mbuya Outreach
Abagala Uganda
Kayunga
FHI 360 Family planning
PACE HIV and TB
Strides MNCH
Joint Action for Health
99
Buvuma
PACE Health communication and
education
Makerere University Walter
Reed Project
Export clients from
communities
Envision Train in mass treatment of
bilharzia
Jinja
TASO HIV/AIDS
PACE HIV and TB
Sustain project Data collection for health
information
Mukono
Omni-med Training VHTs
PACE HIV and TB
World vision Nutrition and sanitation
Buikwe
World vision HIV testing
UNICEF Family health days
Walter reed project
PACE Malaria
THETHA
Iganga
PACE Malaria
Star EC TB, HIV, Malaria
South Western
Kisoro SPRING Nutrition
AMREF Maternal and family based
health care
Muhabura HIV/ Sanitation
Mayanja memorial hospital HIV, Malaria
Water School Project Kisoro
Doctors of Global Health
Mitooma
Global fund Distribution of mosquito nets
Star SW HIV and TB
Church of Uganda HIV
100
Buhweju
Star SW HIV, TB
Malaria Consortium ICCM
UNICEF Registration
Ntungamo
Star SW HIV
UNICEF Immunization
Health child Maternal health
Kabale
PACE HIV
World Vision AIM project
Mayanja Memorial Hospital HIV, Malaria
Reproductive Health Uganda Reproductive health,
Maternal health, HIV
management,
Star SW HIV
Community Connector Nutrition
Kanungu
UNFPA Family planning
ACLAIM Nutrition
Star SW HIV
UNICEF Nutrition
Bushenyi
Health Child Uganda Maternal health
Star SW HIV and TB
UNICEF Nutrition
TASO HIV/AIDS
Uganda Sanitation Fund Sanitation
Sheema UNICEF Immunization
Star sw HIV
Marie stopes Family planning
TASO HIV/AIDS
Reproductive Health Uganda Reproductive health,
Maternal health, HIV
management
Church Of Uganda tuberculosis and HIV
UNHCO
101
ICOB HIV
Mbarara Health child Maternal health
TASO HIV testing and counseling
Uganda Sanitation Fund sanitation
Coin Uganda
ICOB HIV
Reproductive Health Uganda Reproductive health,
Maternal health, HIV
management
Isingiro UNHCR Child health
Mayanja Memorial Hospital HIV, Malaria
PACE ICCM
Church Of Uganda tuberculosis and HIV
Aids Information Center HIV/AIDS
Medical Teams Association
Star Sw HIV
ICOB HIV
Rukungiri AMREF Saving lives at birth
PACE HIV
Star sw HIV
Agape
RUGADA Capacity building
MCSP
RODNET
kiruhura
UNICEF ICCM
Star SW HIV and tuberculosis
African Evangelism Enterprise malaria, tuberculosis and HIV
Ibanda
Star SW HIV and tuberculosis
community connector
Mayanja Memorial HIV, Malaria
African Evangelical
Enterprise(COU)
malaria, tuberculosis and HIV
102
Western
Hoima Malaria Consortium Malaria
World Vision Immunization
Care Uganda HIV
Reproductive Health Uganda Reproductive health,
Maternal health, HIV
management
Infectious Disease Institute Safe deliveries
Kyegegwa UNICEF HIV
Baylor Uganda Immunization
Church of Uganda HIV
Kabarole
Baylor Uganda HIV
International Development
Initiative
Reproductive Health Uganda Reproductive health,
Maternal health, HIV
management
PACE Malaria
Church Of Uganda Malaria, tuberculosis and HIV
Community based ARV DOTS
project
HIV/AIDS
Kibaale
World Vision HIV
Malaria Consortium Malaria
Save Foundation
Infectious Disease Institute Safe deliveries
Uganda Rural Development
Program
EMESCO
Kyenjojo
Baylor Uganda HIV
Strides Family planning
UNICEF Child health program
Samaritan Purse Sanitation and hygiene
NGO Forum Capacity building
103
PACE Malaria
Marie Stopes Maternal health
Kind Uganda
Malaria Consortium Malaria
Church Of Uganda tuberculosis and HIV
NGO-CBO
Bundibugyo
Baylor Uganda HIV
World Vision Child survival
Save The Children Maternal/child health
PACE HIV
World Health Organization Reproductive health and
family planning and nutrition
Belgian Technical Cooperation Capacity Buliding
UNICEF Immunization, Nutrition
Ntoroko
Baylor Uganda HIV
UNICEF Family health days and
immunization
Save The Children Mother child health
Save Foundation
Ride Africa
Rwebisengo Post Test
Association
Karugutu people living with
HIV/AIDS
HIV/AIDS
Rubirizi
Health Child Uganda Maternal health
Church Of Uganda TB
Mayanja Memorial Hospital HIV, Malaria
COVOID
Kamwenge
World Vision Capacity building for VHTs
Strides Capacity building
Mild May Capacity building
UNICEF Immunization, Nutrition
Carter Centre
104
PACE Malaria
Kasese UNICEF Immunization, Nutrition
North
Kaberamaido Pilgrim Africa Malaria,
Baylor Uganda TB, HIV/AIDS
PACE Malaria
Oyam
Communication For
Development Foundation
Uganda
Reproductive health
Uganda Health Marketing
Group
Condom distribution
Family Health International Reproductive health and
family planning
Nu-Hites HIV/AIDS and community
mobilization
Marie Stopes Family planning
World Vision Nutrition
Transparency International
Global Refugee International HIV
Plan Uganda Malaria
UNHCO
GHN
THETA
Kole Nu-Hites Safe male circumcision,
immunization, malaria
Crane Health Services HIV, Malaria and TB
World Vision HIV/AIDS, Sanitation,
immunization, family planning
UNICEF Immunization
ABT associates
Alebtong
Plan Uganda Malaria
Nu-Hites Malaria, TB, HIV
Divine Waters Uganda
PACE Malaria
105
Dokolo Uganda Health Marketing
Group
Malaria
Crane Health Services NTDs
Nu-hites Malaria, TB, HIV
PACE Malaria
Uganda sanitation fund Sanitation and hygiene
Community connector Nutrition
ABT associates
Apac
Nu-Hites Malaria, TB, HIV
LICODA HIV/ Family planning
Lira
Plan Uganda Adolescent
Nu-Hites HIV, Malaria and TB
Marie Stopes Reproductive health
TASO HIV/AIDS
PACE Malaria
Reproductive Health Uganda Reproductive health,
Maternal health, HIV
management
Otuke
Crane Health Services Malaria, TB, HIV
UNICEF Immunization
Marie Stopes Reproductive health
Amolatar
CEPA
JCRC HIV
Lango Samaritan Initiative HIV/AIDS
Nuhites Malaria, TB, HIV
Agago
AVSI ICCM
PACE ICCM
Kitgum AVSI ICCM
International Rescue
Committee
PMTCT
106
Nuhites Malaria, TB, HIV
UNICEF
Child fund Maternal health
AMREF Malaria and HIV
World Vision Nutrition
Pader
AVSI ICCM
SAVE The Children ICCM
Nuhites Malaria, TB, HIV
Carter Centre
AMREF Malaria and HIV
Lamwo International Rescue
Committee
ICCM
AVSI ICCM
KAMPALA
Gomba Malaria Consortium Malaria
Mild May HIV/AIDS
Uganda health marketing
group
Family planning
Bulisa
Infectious Disease Institute HIV/AIDS
Malaria Consortium ICCMs
World Vision Reproductive health, nutrition
and sanitation
Masindi
Malaria Consortium Malaria, diarrhea, Pneumonia
SCIPHA HIV/AIDS
TASO HIV/AIDS
International Health Net Work
Sight Savers
CEDO
Mubende
World Vision Water and sanitation
PACE Reproductive health
UNFPA Reproductive health
PATH Family planning
SNV
107
UNICEF Nutrition
Mild may HIV/AIDS
Mityana
FHI 360 Reproductive health
SCIPHA HIV/AIDS
Marie Stopes Reproductive health
Mild May HIV/AIDS
Strides Nutrition, child health
Uganda Health Marketing
Group
Reproductive health
Reproductive Health Uganda Reproductive health,
Maternal health, HIV
management
Kiryandongo
Child Fund Water/ sanitation
Action Against Hunger Nutrition
International Rescue
Committee
Water and sanitation,
reproductive health
UNICEF Nutrition
PACE HIV/AIDS
Butambala
Malaria Consortium Malaria prevention
Mild May HIV/AIDS
World Vision Nutrition
Wakiso
UNICEF Total funding
Malaria consortium implementation
Mild may HIV/AIDS
AMREF Circumcision
PACE Malaria
Mpigi
PACE Malaria
Malaria Consortium ICCM
Strides Reproductive health
World vision Nutrition
Mild May HIV/AIDS
SCIPHA HIV/AIDS
108
STOP MALARIA Malaria control
WEST NILE
Gulu Nu-hites Malaria, TB, HIV
AVSI ICCM
AMREF
World vision Nutrition
Nwoya AVSI ICCM
PACE Malaria
Amuru AVSI ICCM
World Vision MCH
Nuhites Health facility based VHT
meeting
Koboko UNHCR Supports refugee VHTs
Yumbe UNFPA Reproductive health
Adjumani Baylor Uganda Nutrition assessment
- Immunization
Moyo New Life -
Zombo Baylor Uganda HIV/AIDS
Nebbi Baylor Uganda HIV/AIDS
RTI
Arua UNICEF Nutrition
PREFA HIV/AIDS
Baylor HIV/AIDS
Care International Refugee settlement
Concern Nutrition
Maracha Baylor Uganda HIV/AIDS
SNV(WASH)
RICE(Agriculture) Nutrition
109
CENTRAL 1
Rakai World Vision Nutrition
Kalangala Strides Reproductive health
Kalangala Comprehensive
Health Service
Malaria
Masaka
Uganda Cares HIV
PREFA PMTCT
Mild May HIV
Red cross Reproductive health
Kalungu Malaria Consortium All VHT activities
TASO HIV/AIDS
Mild may HIV
Uganda cares HIV
Lwengo
PACE Malaria
CDC
TASO HIV/AIDS
Malaria consortium Supply of drugs
Bukomanasimbi
PACE Malaria
Malaria Consortium Malaria
Mild May HIV/AIDS
Uganda Cares HIV
Villa Maria
Karitas MADDO
Ssembabule - -
Lyantonde PACE Malaria
Mild may HIV/AIDS
Care Uganda HIV
110
Appendix 6.4 List of partners interviewed at district level
District Partner
Arua Baylor
Adjumani Baylor
Bududa. PONT (PERTENERSHIP OVERSEAS NETWORK
TRUST
Bukedea BAYLOR
Bulambuli PACE
Bundibugyo Save the Children International
Hoima WORLD VISION
Kibaale Infectious Diseases Institute
Ntoroko RIDE AFRICA
Rubiriizi
Health Child Uganda
Kaliro Envision
Oyam World Vision Uganda
Kitgum AVSI
Kumi BAYLOR UGANDA
Kyegegwa Humura Archdeaconry ….Church Of Uganda
Maracha Baylor
Masaka Uganda Cares
Mbale MALARIA CONSORTIUM
Mbarara Healthy Child Uganda
Mityana REPRODUCTIVE HEALTH UGANDA(RHU)
MITYANA OFFICE
111
Moyo Baylor
Dokolo NU-HITES
Kiryandongo CHILD FUND
Kamuli
PLAN Uganda
Butaleja Mazimasa Community Development
Association (Implementing for Child Fund)
Gomba Gomba Aids Support and counseling
organization {GASCO}
Abim Community action for Health (CAFH)
Amudat Friends of Christ Revival Ministry(FOCREV)
Amuria Partners for Children WORLD WIDE
Kaabong CUAAM (INGO
Katakwi LWF (Lutheran World Federation)
Kotido International Rescue Commission (INGO
Moroto UNICEF MOROTO
Nakapiripirit Doctors With Africa- CUAAM (INGO)
Napak International rescue committee (IRC)
Kibuku Kagum Development Organization (KADO)
BUSIA World Vision Uganda
Kiboga World Vision
Luwero Plan Uganda
Palisa Maternal and Neonatal Implementation for
Equitable Systems
Nakaseke BUSOGA TRUST
Nakasongola World Vision
112
Kaberamaido Baylor Uganda
Lira Marie Stopes
Buyende STAR EC
Budaka
Child Fund (Kadenge Children’s Project)
Kibuku
Kadama Widows Association
Namutumba USAID SPRING
Sheema ICOBI (Integrated Community Based
Initiatives)
Mpigi Mild May
Kabale AMREF
Ntungamo Uganda Red Cross Society
Mubende PACE(Program For Accessible Health
Communication And Education)
Alebtong Plan International
Sironko Buyobo Community Development Association
Soroti
WORLD VISION
Kamwenge World Vision
Kabarole Baylor
Kapchorwa Kapchorwa Integrated Community
Serere BAYLOR UGANDA
MANAFA
TASO
113
Appendix 6.5 Ministry of health KIIs
1. Director General
2. Assistant commissioner, Health Promotion and Education
3. Assistant commissioner, Community Health
4. Assistant Commissioner, Reproductive Health
5. VHT Coordinator
6. Director, Clinical and Community Health
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Appendix 6.6 VHT Questionnaire
General information
1. Date of interview (dd/mm/yyyy)
2. District
3. Sub-county
4. Parish
5. Village
6. Name of interviewer & contact
7. Name of the VHT member and contact
8. Age
9. Sex 1) Male
2) Female
10. M
M
Highest level of education attained (including
vocational skills)
1)P.7
2) 0-Level
3) A-level
4)Tertiary
5)University
1. Marital status 1)Single
2)Married
3)Divorced
4)Widowed
2. Occupation (other than VHT work) 1)Farmer
2)Business
3)Employed by Govt
4)Employed by NGO
5)Student
6)Other specify
________________________
3. Name and level of Health facility the VHT is
attached to
4. How were you selected to become a VHT
member?
5. Have you been trained as a VHT member?
6. When were you trained as a VHT member?
7. How many times have you received training?
115
8. How long was the training?
9. Who conducted the training?
10. What was covered in the training 1)Disease prevention
2)Community mapping
3)Community registers
4)Home visits
5)Community mobilization
6)Health education
7)Referrals
8) Others (specify)
________________________
__
11. How was the training done 1)Brain storming
2)Group discussions on
specific issues
3)Role plays
4)Games
5)Field visits
6)Sharing experiences
7)Practicing what has been
learned
8)Refresher sessions after
training to strengthen
weaknesses found during
supervision
12. How long have you served as a VHT member? 1) 6 months to 1 year
2) 1 year to 2 years
3) 2-5 year
4) More than 5 years
(specify)………………
13. What has kept you active?
14. What were your expectations as a VHT member?
116
15. Have the above expectations been met?
16. If no, suggest areas of improvement
17. What are your roles as a VHT member? 1) Mobilize the community
for health action
2) Promote health to prevent
disease
3) Treat simple illness at
home 4) Checks for danger
signs in the community
5) Report and refers
community sickness to health
workers
6) Keep village records up to
date
7) Others specify
________________________
_
18. What activities have you done as a VHT member? 1) Disease prevention
2) Community mapping
3) Community registers
4) Home visits
5) Community mobilization
6) Health education
7) Referrals
8) Treat simple illness at
home 9) Checks for danger
signs in the community
Others (specify)
________________________
__
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19. How many other VHT members are in your
Village
20. In how many village(s) do you work?
21. Have you received any additional training
following the basic training? YES/NO
If yes, specify………………………..
1)Yes 2)No
Specify__________________
________________________
________________________
22. Have you been supervised in the last 6 months?
If yes, by who? Specify………………………….
1)Yes 2)No
23. What support did you get from your supervisor?
1) Observation of service
delivery (use of Job
Aids, RDT
2) Coaching and skill
development
3) Hygienic practice
4) Trouble shooting (this
is technical advice)
5) Problem solving (non
technical)
6) Home visit
7) Record review
(Register, stock cards)
8) Supply check
(Medicines, )
Others (specify)………
24. During your activities, have you ever received any
assistance from the Local Council?
1)Yes 2)No
25. If yes, which assistance? 1) Inform communites about
VHT
2) Advocacy for health at
home
3) Mobilize communities for
health
4) Supervision of VHT
activities
5) Give financial support
6) Planning for VHT in district
118
and village health plans
7) Attend and support health
events
8) Others (specify)
________________________
__
26. Do you have the supplies and equipment
you need to provide the services you are
expected to deliver?
1) Yes
2) No
3) Some
27. If yes which supplies and equipments do you
have? (Please verify)
1) Condoms
2) Register
3) Report book
4) Badges, t-shirts, bags
5) Job Aids (flip charts,
counseling cards, VHT
manual, e.t.c.)
6) IEC materials
7) Identity cards
8) Bicycle
9) Others (specify)………..
ADDITIONAL
Amoxacilin
Coartem
ORS
Zinc
Lectoatersunate
RDT kit
Gloves
Respiratory timers
Mobile phones
Solar chargers
Wrist watch
Tippy tap materials
28. How do you keep the supplies/medicines? 1. Wooden box
2. Plastic bag
119
3. Others (please specify)
29. What additional logistical support have you
received as a VHT member to facilitate your
activities?
30. Who provided these
supplies/equipment/medicines? Specify
31. In the last six months, have you participated
in a VHT review meeting?
1) Yes
2) No
32. Have you ever had a meeting/dialogue with
the community to give you feed back on your
services?
1) Yes
2) No
33. If yes, who participated in the feed back
meeting?
1) LC 1
2) Parish leaders
3) Health workers
4) Community members
5) Partners
34. 29. How does your community support you
in work as a VHT? (please tick appropriately)
For example
1) Feed back
2) Support (financial or
gifts in kind)
3) Guidance on your work
4) Formal recognition/
appreciation
5) Others (specify)
Referral of patients
35. What do you do when you get clients who
need health services that you can not
provide?
1) Referral
2) Others (specify)……
…………………………
…………………………
36. If the answer above is referral how do you
refer?
1) Fill out form
2) Write in the book
3) Other (specify)
……………………….
……………..
37. Do you have referral forms?
If yes, verify availability of referral forms
1) Yes
2) no
120
38. If yes, are they Ministry of Health referral
forms?
1) Yes
2) No
39. In the last one month did you refer any client
to the health facility?
1) Yes
2) No
40. If yes, where was the client referred? 1) Government health facility
2) Private health facility
3) Others (specify)……….
41. Did you follow up any of the referred clients? 1) Yes
2) No
42. What category of clients did you follow up? 1) pregnant women
2) post natal mothers
3) clients on long term
treatment
4) new borne
5) Under fives
6) others (specify)
………………………….
…………………………
43. What challenges do you face during referral?
(Health facility related)
44. What challenges do you face during referral?
(Client related)
45. Do you have a VHT/ICCM register? 1) Yes
2) No
46. What do you record in the register? (please
verify)
……………………………..
…………………………….
…………………………….
47. How do you use the information you collect? ……………………………..
……………………………..
……………………………..
48. Where do you submit your monthly and
quarterly reports?
……………………………..
……………………………..
49. Are these reports shared with the
community?
1) Yes
2) No
50. If yes in which ways do you share the reports ……………………………..
……………………………..
121
51. If no, why?
52. What challenges do you find in the course of
your work?
53. How do you think these challenges can be
rectified?
THANK YOU VERY MUCH FOR PARTICIPATING IN THIS INTERVIEW.
122
Appendix 6.7 Questionnaire for Ministry of Health officials
1. DEMONSTRATION OF MOH COMMITMENT TO IMPLEMENT VHT STRATEGY
Does the Ministry have a budget line to implement the VHT strategy?
In the last two quarters what has the Ministry done with VHT allocation?
What plans are in place for resource mobilization for VHT strategy?
What advocacy activities have been carried out to promote the roll out of the VHT
strategy? (Influence policy, resource allocation, integration etc)
What are the supervision mechanisms in place?
What Quality control measures are in place and how is it done?
2. COORDINATION
How are the VHT activities coordinated from national to community level?
Are there any reports on coordination in the last two quarters?
Who is the focal person for VHTs at the Ministry?
What is the linkage between MoH and the districts in coordinating VHT interventions?
Does VHT working group exist? If yes, explain its functionality.
How can the coordination be strengthened?
How does MOH work with other partners in supporting VHTs
3. POLICY FRAME WORK
What policies and guidelines are in place to guide the VHT implementation? Are they
available?
Has there been any review of policies and guidelines to meet new challenges and
innovations?
Have policies and guidelines been disseminated to districts and partners?
4. SUSTAINABILITY
What mechanisms are in place to ensure continuity of established VHTs? - How
often are the VHT kits, tools, registers, T-shirts replenished?
- Are there planned refresher courses for VHTs? If yes, verify.
How has the Ministry utilized lessons and best practices learnt from other countries
and other partners?
123
5. MOTIVATION
Are there guidelines that define standard package for VHT motivation?
Are these guidelines being adhered to by partners?
What needs to be improved /harmonized to increase the morale of the VHTs to
serve their community's health needs?
6. DATABASE ON VHTS
Does the MOH have a data base for VHTs?
If no, what are the plans for establishing the database?
If yes, when was it last updated?
Is the existing database adequate?
What plans do you have to improve/update the database?
7. CHALLENGES
What challenges have you encountered in implementing the VHT strategy? (consider
political, Technology, economics, social, legal, environment)
What are the possible solutions to overcome these challenges?
8. RECOMMENDATIONS
Suggest ways of improving the VHT implementation framework?
What suggestions do have for improvement of VHT functionality?
What suggestions do you have for sustainability of VHTs functionality?
124
Appendix 6.8 Partner interview guide
General information
Name of Organisation…………………………………………………………………………
Name of respondent……………………………………………………………………………
Position of respondent……………………………………………………………………………
Phone number of respondent…………………………………………………………………
Name of interviewer………………………………………………………………………………
1. What activities does this organization do?..............................................................
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
……………………………….
2. When did you start supporting VHTs in Uganda?...................................................
3. How have you been supporting VHTs in Uganda?
a) Strengthening the national capacity to provide quality VHT strategy implementation
b) Providing technical advice
c) Funding for core activities
d) Drugs and other supplies and logistics
e) Advocacy
f) Training VHTs
g) Others (specify)…………………………………………………………………………
…………………………………………………………………………………………………………………………………………
……………………………………………………
4. If funding, how much funds have you so far spent in regard to VHT support?....................
.............................................................................................................................
5. How do you know how your resources have been utilized?..................................
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
…………………………………………..
6. How are you involved in the planning and evaluation processes?...................
125
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
……………………
7. Has this organization been involved in training of VHTs? a) Yes b) No
8. In which districts has this organisation carried out the training?..........................
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………
9. What areas did you train on?
a) Provide appropriate information about disease prevention and health promotion
Correctly classify simple illnesses and give simple treatment
b) Referring cases they cannot manage
c) Referring cases with danger signs or complications
d) Maintaining simple, village register and reporting
e) Recognizing community members in need of rehabilitation and refer them to the
appropriate services
f) Skills such as direct observation of therapy or community case management (Fever,
pneumonia ,malnutrition
g) Others (Specify)……………………………………………………………………
…………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………
………………………….
10. What methods did you use to train the VHTs?
a) Brain storming
b) Group discussions on specific issues
c) Role-plays
d) Games
e) Field visits
f) Sharing of experiences.
g) Practicing what has been learned
h) Refresher sessions after training to strengthen weaknesses found during supervision
i) Additional topics according to new developments or health needs of the community.
j) Others (Specify)……………………………………………………………………
126
…………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………
…………
11. How many trainings has this organization so far offered?......................................
12. What challenges do you think face VHT implementation in Uganda? ……………………
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………
13. What do you think can be done to improve VHT operations?
127
Appendix 6.9 Health Centre interview guide
General information
District……………………………………………………………………………………………...
Subcounty………………………………………………………………………………………….
Parish………………………………………………………………………………………………
Village……………………………………………………………………………………………
Name of health centre……………………………………………………………………………
Name of respondent…………………………………………………………………………
Position of respondent……………………………………………………………………………
Phone number of respondent……………………………………………………………………
Name of interviewer………………………………………………………………………………
1. How long have you been working here?...........................................Years
2. How many villages does this health centre cover?.................................................
3. How many households does this health centre cover?...........................................
4. How many VHTs operate under this health centre?...............................................
5. What are the functions of VHTs
a) Community Information management,
b) Health Promotion and Education
c) Mobilization of communities for utilization of health services and health action
d) Simple community case management and follow up of major killer diseases (Malaria,
Diarrhoea, Pneumonia) and emergencies
e) Care of the newborn
f) Distribution of health commodities
6. What diseases do the VHTs treat in the communities? 1) Malaria 2) Diarrhea,
3)Pneumonia, 4)Malnutrition
7. Do VHTs usually refer community members to this health centre? 1) Yes 2) No.
8. Under what circumstances do the VHTs refer community members to a health centre?
a) ALL Pregnant women, newborns or children or other person with danger signs
including red on the MUAC strap.
b) Anyone with sudden recent loss of visual acuity, or a painful red eye or recent
inability to close the eye
c) Accidents or injuries.
d) ALL conditions without danger signs for which the VHT has not received specific
training, or if the VHT does not have the necessary medications
e) Routine outpatient or outreach referrals for Immunisation, Antenatal Care, Post
natal care (Mother and Infant)
128
f) Referral of children >6months with mid arm circumference (MUAC) yellow.
g) All conditions which require rehabilitation e.g after injury, patients with leprosy.
h) Others (specify)……………………………………………………………………
………………………………………………………………………………………….………………………………………
…………………………………………………..
9. What roles do VHTs play at this health centre?
a) VHTs refer patients to HC II/III/IV.
b) VHTs follow-up patients discharged from the health centres.
c) VHT members can serve as health management committee of Health Centre II.
d) VHTs assist at clinics and outreach
10. How does this health facility help VHTs to perform their duties?
a) The VHT benefit from the training facilities of HCII/III/IV
b) The VHT receives training, support and supervision from Health Centres.
c) Commodities e.g kits for use at community level are stored
d) Supervision of the VHTs
11. What constraints do you think face VHT operations in communities around this health
centre?............................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..................................................................................................................
12. How do you think VHT operations can be improved?.............................................
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
……………………
129
Appendix 6.10 Community interview guide
General information
District……………………………………………………………………………………………...
Subcounty………………………………………………………………………………………….
Parish………………………………………………………………………………………………
Village………………………………………………………………………………………………
1. How many households are in this village?
2. How many VHT members do you have in this village?
3. How were VHTs formed in this community (Guiding principles)?
4. What is the composition of the VHTs as regards to gender (how many men vs women)
5. Do you know the functions of VHTs?
6. What are they?
7. What diseases do VHTs usually work treat?
8. How do VHTs relate to LCs (what activities do they do together, how do LCs help VHTs to
do their work?)
9. How do VHTs relate to health centres (what activities do they do together, how do
health centres help VHTs to do their work?)
10. How do VHTs relate to households and communities (what activities do they do
together, how do households and the communities help VHTs to do their work?)
11. Who monitors VHTs in this community? How is monitoring done?
12. Have you benefited from the existence of VHTs in this community? How?
13. How do you think VHTs can be improved to perform better?
130
Appendix 6.11 District key informant Guide (LCV Chairman, CAO, RDC)
Name of the Key informant__________________________
Title of the key informant_____________________________
Contact of the key informant----------------------------------------------
1. What do you know about VHT?
2. Is there any mobilization of district leadership about VHT program?
3. How is the district supporting VHT activities?
4. Do you sometimes supervise VHT activities? How?
5. What does the district do to motivate VHTs?
6. What do you feel about the contribution of VHTs in promoting health services
7. What challenges does the district find in implementing the VHT program?
8. Suggestions to improve the VHT program
131
7.0 References
Ministry of Health (MoH) Uganda 2009a, “Operational guidelines for establishment
and scale up of village health teams”.
Ministry of Health (MoH) Uganda 2009b, “Situation Analysis, Village Health Teams
Uganda 2009”.
Ministry of Health (MoH) Uganda, “Village Health Team, Facilitator`s Guide for
Training Village Health Teams.
Ministry of Health (MoH) Uganda, “Village Health Team, Guide for Training the
Training of Village Health Teams.
World Vision Uganda 2014, “Improving Maternal New born and Child Health through
Village Health Teams in Uganda. A VHT AIM Functionality Assessment Report.
Health Sector Strategic Plan 2000/01 – 2004/05, Ministry of Health.
Health Sector Strategic Plan 2005/06 – 2009/10, Ministry of Health.
